How should I manage a non‑pregnant adult with type 2 diabetes and an HbA1c of 6.8% (estimated average glucose 148 mg/dL)?

Management of Type 2 Diabetes with HbA1c 6.8%

You should consider deintensifying pharmacologic therapy at this HbA1c level of 6.8%, as no clinical trials demonstrate improved mortality or cardiovascular outcomes with treatment below 6.5%, and targeting levels this low increases risks of hypoglycemia and death. 1

Current Status Assessment

Your HbA1c of 6.8% (estimated average glucose 148 mg/dL) places you below the 7-8% target recommended for most adults with type 2 diabetes. 1 This level is actually too low for optimal risk-benefit balance in most patients, particularly if achieved through medications that carry hypoglycemia risk. 1

Evidence-Based Target Range

• The appropriate HbA1c target for most adults with type 2 diabetes is 7-8%, based on the American College of Physicians' 2018 guidance statement that prioritizes mortality and quality of life outcomes. 1

• Targeting HbA1c below 6.5% has been associated with increased overall mortality and cardiovascular death, as demonstrated when the ACCORD trial was stopped early due to excess deaths in the intensive control group (achieved HbA1c 6.4%). 1

• The ADVANCE study similarly failed to show clinical benefit at an achieved HbA1c of 6.4% compared to 7.0%, while documenting more adverse effects in the lower target group. 1

Recommended Treatment Modifications

If Currently on Multiple Medications:

• Deintensify therapy by reducing medication dosages, removing one agent if on combination therapy, or discontinuing pharmacologic treatment entirely. 1

• Priority for discontinuation should be medications associated with hypoglycemia (sulfonylureas, insulin) or significant side effects. 1

If Currently on Metformin Alone:

• Metformin may be continued as it does not cause hypoglycemia, is generally well-tolerated, and is low cost, though the benefit-harm balance becomes uncertain at HbA1c levels below 7%. 1

• Consider dose reduction if the patient experiences gastrointestinal side effects or other adverse effects. 1

If Currently on Newer Agents (SGLT2 inhibitors, GLP-1 agonists):

• These medications carry low hypoglycemia risk and may provide cardiovascular or renal benefits independent of glucose lowering. 2

• Continuation may be reasonable if prescribed for indications beyond glycemic control (heart failure, chronic kidney disease, cardiovascular disease prevention). 2

Exceptions Requiring Lower Targets

A target HbA1c of 6.5-7.0% may be appropriate ONLY if you meet ALL of the following criteria:

• Newly diagnosed diabetes (within 1-2 years) 1, 2
• Life expectancy greater than 15 years 1
• Absence of established cardiovascular disease or microvascular complications 2
• Target achievable with lifestyle modifications alone or metformin monotherapy without hypoglycemia risk 1, 2
• Patient preference for more intensive control after informed discussion of risks 1

Monitoring Strategy

• Recheck HbA1c in 3 months after any medication adjustments to ensure levels remain in the 7-8% target range. 3

• If HbA1c rises above 8% after deintensification, consider re-intensifying therapy to bring levels back to the 7-8% target. 2

Critical Pitfalls to Avoid

• Do not pursue HbA1c levels below 6.5% with pharmacologic therapy - this approach increases treatment burden and mortality risk without improving clinical outcomes. 1

• Avoid the misconception that "lower is always better" - the relationship between HbA1c and outcomes is U-shaped, with increased mortality at both very high and very low levels. 1

• Do not ignore medication-related harms in pursuit of glycemic targets - hypoglycemia, weight gain, and polypharmacy burden significantly impact quality of life. 1

Lifestyle Optimization

Regardless of medication adjustments, continue emphasizing:

• Weight loss of 5-10% if overweight or obese through caloric restriction. 3

• Regular aerobic exercise (minimum 150 minutes weekly) combined with resistance training. 3

• Dietary modifications focusing on reduced refined carbohydrates and portion control. 3

• Smoking cessation, blood pressure control, and lipid management - these interventions may provide greater cardiovascular benefit than intensive glycemic control for many patients. 1