Update from the ACP: New Hemoglobin A1c Targets for Type 2 Diabetes Mellitus

SUMMARY:

The ACP has updated guidance to help providers better target hemoglobin A1c (HbA1c) targets for the pharmacologic treatment of type 2 diabetes. The ACP recommends

Clinicians should personalize goals for glycemic control in patients with type 2 diabetes on the basis of a discussion of benefits and harms of pharmacotherapy, patients’ preferences, patients’ general health and life expectancy, treatment burden, and costs of care.

Clinicians should aim to achieve an HbA1c level between 7% and 8% in most patients with type 2 diabetes.

Clinicians should consider deintensifying pharmacologic therapy in patients with type 2 diabetes who achieve HbA1c levels less than 6.5%.

Clinicians should treat patients with type 2 diabetes to minimize symptoms related to hyperglycemia and avoid targeting an HbA1c level in patients with a life expectancy less than 10 years due to advanced age (80 years or older), residence in a nursing home, or chronic conditions (such as dementia, cancer, end-stage kidney disease, or severe chronic obstructive pulmonary disease or congestive heart failure) because the harms outweigh the benefits in this population.

KEY POINTS:  

Other guidelines reviewed in this document include  

• The ADA guidelines set the following targets  
  • <7% for the general population 
  • Consider less stringent goals (<8%) for patients with limited life expectancy or significant comorbidities
  • Consider more stringent goals (<6.5%) for selected patients without significant hypoglycemia  
    • Short duration of diabetes 
    • Type 2 diabetes treated with lifestyle or metformin only 
    • Long life expectancy 
    • No CVD  

Note: The ADA has issued a statement that it is “deeply concerned by the new guidance” and “that a reasonable A1c goal for many nonpregnant adults with type 2 diabetes is less than 7 percent based on the available evidence to date from the ACCORD, ADVANCE, VADT and UKPDS international clinical trials, which were evaluated and incorporated into ADA’s Standards of Care.” (see ‘Learn More – Primary Sources’ below)

• Scottish Intercollegiate Guidelines Network (SIGN) guideline is similar to ADA  
• AACE/ACE  
  • ≤6.5% if target can be achieved safely  
• NICE  
  • 6.5% for patients managed with 
    • Lifestyle and diet 
    • Lifestyle and diet with single drug and no hypoglycemia 
  • 7% for patients on medications associated with hypoglycemia  
• Institute for Clinical Systems Improvement  
  • < 7% to < 8% based on patient factors 
• VA/DoD  
  • 6% to 7% for patients with a life expectancy > 10 to 15 years and no or mild microvascular complications 
  • 7% to 8.5% for those with established microvascular or macrovascular disease, comorbid conditions, or a life expectancy of 5 to 10 years 
  • 8% to 9% for those with a life expectancy <5 years, significant comorbid conditions, advanced complications of diabetes, or difficulties in self-management attributable to mental status, disability, or other factors (12) 

Review of Literature 

Overall, the ACP did not find that the benefits of lower HbA1c targets justified potential risks 

• ACP reviewed 5 large RCTs comparing intensive (achieved HbA1c levels, 6.3% to 7.4%) versus less intensive (achieved HbA1c levels, 7.3% to 8.4%) treatment targets  
  • Main effect: More intensive glycemic control resulted in small absolute reductions in risk for microvascular surrogate events (e.g., retinopathy on ophthalmologic screening) but not clinical events such as loss of vision  
  • One trial of metformin in overweight adults showed a reduction in all-cause and diabetes-related death through at least 10 years 
  • In all studies, more intensive therapy required higher dose medications and was associated with more adverse events (including increased risk of death in 1 study) 

NOTE: All guidelines allow for higher HbA1c targets depending on comorbid conditions and limited life expectancy 

Learn More – Primary Sources:  

Hemoglobin A1c Targets for Glycemic Control With Pharmacologic Therapy for Nonpregnant Adults With Type 2 Diabetes Mellitus: A Guidance Statement Update From the American College of Physicians

American Diabetes Association® Deeply Concerned About New Guidance from American College of Physicians Regarding Blood Glucose Targets for People with Type 2 Diabetes

ADA: Glycemic Targets: Standards of Medical Care in Diabetes—2022

American Association of Clinical Endocrinology Clinical Practice Guideline: Developing a Diabetes Mellitus Comprehensive Care Plan – 2022 Update

NICE: Type 2 diabetes in adults: management

VA/DoD Clinical Practice Guidelines: Management of Diabetes Mellitus in Primary Care