HbA1c Target for Type 1 Diabetes
For most nonpregnant adults with type 1 diabetes, target an HbA1c of <7% (53 mmol/mol), as this significantly reduces microvascular complications including retinopathy, neuropathy, and diabetic kidney disease. 1
Evidence Base
The <7% target is supported by the landmark Diabetes Control and Complications Trial (DCCT), which demonstrated that achieving this level significantly reduces rates of development and progression of microvascular complications. 1 The long-term follow-up Epidemiology of Diabetes Interventions and Complications (EDIC) study confirmed these microvascular benefits persist over two decades. 1 Specifically, each 10% reduction in HbA1c is associated with a 44% lower risk for progression of diabetic retinopathy. 1
When to Adjust the Target
More Stringent Target (<6.5%)
Consider this tighter target for patients who meet ALL of the following criteria: 1
- Short duration of diabetes
- Long life expectancy
- No significant cardiovascular disease
- Can achieve target without significant hypoglycemia
This may be particularly appropriate during the "honeymoon" period when lower mean glycemia is achievable without excessive hypoglycemia or reduced quality of life. 2
Less Stringent Target (<8%)
Use this higher target for patients with ANY of the following: 1
- Limited life expectancy
- Advanced microvascular or macrovascular complications
- Extensive comorbid conditions
- Long-standing diabetes where <7% is difficult to achieve despite optimal management
- History of severe hypoglycemia
- Hypoglycemia unawareness
- Inability to articulate symptoms of hypoglycemia (particularly relevant in children)
- Lack of access to analog insulins or advanced diabetes technologies
- Cannot monitor blood glucose regularly
Special Population: Children and Adolescents
For children with type 1 diabetes, including preschool children, the target HbA1c is <7.5% (58 mmol/mol). 3 This slightly higher target aims to minimize hyperglycemia while reducing severe hypoglycemia, hypoglycemic unawareness, and the likelihood of long-term complications. 3 A higher target of <7.5% may be more suitable for youth who cannot articulate symptoms of hypoglycemia or have hypoglycemia unawareness. 2
Monitoring Strategy
- Check HbA1c at least twice yearly in patients meeting treatment goals with stable glycemic control 1
- Check quarterly in those with therapy changes or not meeting goals 1
- Reassess glycemic targets over time based on changes in patient circumstances 1
Critical Pitfalls to Avoid
Do not set overly aggressive targets (HbA1c <6.5%) for patients with multiple comorbidities or at high risk for hypoglycemia, as intensive glycemic control significantly increases hypoglycemia risk, which can lead to falls, cognitive impairment, and potentially increased mortality. 1 This risk is especially pronounced in patients with advanced kidney disease (CKD stages 4-5). 4
Do not fail to adjust targets as patient circumstances change (e.g., development of complications, aging, new comorbidities). 1 What was appropriate at diagnosis may become inappropriate years later.
Do not overlook the increased risk of hypoglycemia with intensive control, especially in patients with renal impairment where hypoglycemia risk escalates substantially. 1