HbA1c Target Recommendations for Adults with Diabetes
For most adults with type 2 diabetes, target an HbA1c between 7% and 8%, with more stringent goals of <7% reserved for healthier patients with longer life expectancy, and less stringent goals of 7-8.5% for those with complications, comorbidities, or limited life expectancy. 1, 2
Treatment-Specific Targets
The specific HbA1c target depends on your treatment approach:
6.5% (48 mmol/mol): For patients managed with lifestyle/diet alone OR lifestyle/diet plus a single medication NOT associated with hypoglycemia risk 3, 4
7.0% (53 mmol/mol): For patients on medications associated with hypoglycemia (such as sulfonylureas or insulin) 3, 4
7.0% (53 mmol/mol): For patients requiring treatment intensification when HbA1c rises to ≥7.5% (58 mmol/mol) on monotherapy 3, 4
Patient-Specific Target Selection Algorithm
Target <7% (or 6.0-7.0%) if patient has:
- Short duration of diabetes (newly diagnosed or within first few years) 1, 2
- Treatment with lifestyle modifications or metformin only 1, 2
- Life expectancy >10-15 years 1, 2
- Absence of significant cardiovascular disease 2, 4
- No history of severe hypoglycemia 2, 4
- Absent or mild microvascular complications 1, 4
Target 7-8% (or 7.0-8.5%) if patient has:
- History of severe hypoglycemia 1, 2
- Advanced microvascular complications (retinopathy, nephropathy, neuropathy) 1, 2
- Established macrovascular disease (coronary artery disease, stroke, peripheral arterial disease) 1, 2
- Extensive comorbid conditions 1, 2
- Long-standing diabetes that is difficult to control despite multiple medications 1, 2
- Life expectancy 5-10 years 1, 2
- Older adults, particularly those who are frail 1, 2
- Impaired awareness of hypoglycemia 3
- High risk of falls 3
- Occupations requiring operation of machinery or driving 3
Target ≥8% if patient has:
- Life expectancy <5 years 2, 4
- Severe frailty with limited functional status 2, 4
- Advanced dementia or cognitive impairment 2
- Inability to safely manage diabetes medications 4
Critical Pitfalls to Avoid
Targeting HbA1c below 7% increases risk for death, weight gain, and hypoglycemia in many patients, particularly those with established disease or multiple comorbidities. 1, 4 This is especially dangerous in:
- Older adults with frailty 2, 4
- Patients with impaired renal function 2
- Those with cognitive impairment 2
- Patients with history of severe hypoglycemia 1, 2
Consider de-escalating therapy if HbA1c falls below 6.5% to reduce risk of adverse events, especially in older adults or those at high risk for hypoglycemia. 2
Do not delay treatment intensification if HbA1c remains ≥7.5% (58 mmol/mol) after 3 months of optimized monotherapy—this represents inadequate control requiring escalation. 4
Monitoring Frequency
- Twice yearly: For patients meeting treatment goals with stable glycemic control 1, 2
- Quarterly: For patients whose therapy has recently changed or who are not meeting glycemic goals 1, 2
Shared Decision-Making
Involve patients in target-setting decisions and adjust goals if efforts to achieve targets impair quality of life or cause adverse effects such as recurrent hypoglycemia, weight gain, or medication burden. 3, 4 The target should balance microvascular risk reduction against treatment-related harms, with particular attention to hypoglycemia risk in vulnerable populations. 3, 1