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New Guidelines Issued on Optimal Hemoglobin A1C Targets for Type 2 Diabetes

Sep 25, 2007

The American College of Physicians (ACP) has issued a guidance statement on the optimal hemoglobin A1c targets for patients with type 2 diabetes. More confusion?

"This guidance statement is derived from other organizations’ guidelines and is based on an evaluation of the strengths and weaknesses of the available guidelines," write Amir Qaseem, MD, PhD, MHA, from the ACP in Philadelphia, and colleagues from the Clinical Efficacy Assessment Subcommittee of the ACP. "We used the Appraisal of Guidelines, Research and Evaluation in Europe (AGREE) appraisal instrument to evaluate the guidelines from various organizations."

The reviewed guidelines differed in whether they recommended a specific hemoglobin A1c target, as well as in their choice of a specific target hemoglobin A1c level. Except for the American Academy of Family Physicians guidelines, all guidelines specified hemoglobin A1c target levels. Although most guidelines recommend a target hemoglobin A1c level of approximately 7%, several guidelines recommend tailoring the target hemoglobin A1c based on individual patient factors, including risk for microvascular and macrovascular complications, life expectancy, and comorbid conditions. All the reviewed guidelines agreed that target hemoglobin A1c levels should be individualized for specific patients.

After reviewing the available guidelines, the ACP committee issued 3 summary statements:

Statement 1: The goal for glycemic control should be set as low as is feasible to prevent microvascular complications of diabetes, while avoiding undue risk for adverse events or placing an unacceptable burden on patients. Discussing with the patient the risks and benefits of specific levels of glycemic control should precede setting treatment goals.

Based on individualized assessment, a hemoglobin A1c level less than 7% is a reasonable target for many patients, but not for all. Hemoglobin A1c goals higher than 7% may be indicated for patients who are elderly or frail, who are at higher risk for adverse events from tight control, or who have substantially lowered life expectancy from comorbid conditions. More stringent targets may be indicated in patients who are at increased risk for microvascular complications.

Statement 2: Individualized evaluation of risk for complications from diabetes, comorbidity, life expectancy, and patient preferences should determine the specific goal for hemoglobin A1c level.

Statement 3: The ACP committee recommends additional research to evaluate the optimal level of glycemic control, particularly in patients who have significant comorbid conditions.

"Understanding the benefits and harms of various levels of glycemic control remains challenging, particularly in patients with other comorbid conditions," the authors conclude. "In addition to the importance of glycemic control, management of blood pressure and lipid levels is also essential to prevent complications of diabetes. Further research that elucidates optimal level of glycemic control in patients of different ages, in patients with comorbid conditions, and in patient populations representative of those seen in practice would provide important additional guidance for management of diabetes."
Ann Intern Med. 2007;147:417-422.
Publishers comment:
What should your A1c be? 

Below 7%, below 6.5% OR NORMAL?
When do we get honest with the public and tell them the truth?  To reduce your risks as if you did not have diabetes, then you need an A1c that represents a healthy individual without diabetes.  The studies have shown that a normal A1c for a healthy person without diabetes should be 4.3 to 4.6%. In the Epic-Norfolk study they showed that an A1c of 5% compared to an individual with an A1c of 6% had an increased risk of cardiovascular death of 28% higher. 

In all of the recommendations they say that the A1c should be as low as possible without hypoglycemia.  The ADA sticks with 7% or below, AACE stays with 6.5% or below, what does below mean?    When we say it should be 7 or below then that is usually where most medical professionals stop being aggressive.  We hear 7% we hear 6.5 % we even sometimes hear 6%.

If your child  had diabetes, would you be satisfied at 6.5% or would you want it Normal, as if they did not have diabetes?    Or would you like to wait 15 years and see what the studies tell us?


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