Update from the ACP: New Hemoglobin A1c Targets for Type 2 Diabetes Mellitus
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.
Other guidelines reviewed in this document include
The ADA guidelines set the following targets
<7% for the general population
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
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
≤6.5% if target can be achieved safely
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
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
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