Targets for Glycemic Control

Canadian Diabetes Association Clinical Practice Guidelines Expert Committee

S. Ali Imran MBBS, FRCP(Edin), FRCPC Rémi Rabasa-Lhoret MD, PhD Stuart Ross MB, ChB, FRACP, FRCPC

  • Key Messages
  • Recommendations
  • Figures
  • Highlights
  • Full Text
  • References

Key Messages

  • Optimal glycemic control is fundamental to the management of diabetes.
  • Both fasting and postprandial plasma glucose levels correlate with the risk of complications and contribute to the measured glycated hemoglobin (A1C) value.
  • Glycemic targets should be individualized based on the individual’s age, duration of diabetes, risk of severe hypoglycemia, presence or absence of cardiovascular disease and life expectancy.

Highlights of Revisions

  • New recommendation better defines the scenarios in which one can consider less stringent glycated hemoglobin (A1C) targets (7.1% to 8.5% in most cases).

Figure 1
Recommended targets for glycemic control.

Recommendations

  1. 1.Glycemic targets should be individualized based on age, duration of diabetes, risk of severe hypoglycemia, presence or absence of cardiovascular disease, and life expectancy [Grade D, Consensus].
  2. 2.Therapy in most individuals with type 1 or type 2 diabetes should be targeted to achieve an A1C ≤7.0% in order to reduce the risk of microvascular [Grade A, Level 1A (1,2) ] and, if implemented early in the course of disease, macrovascular complications [Grade B, Level 3 (3,4)].
  3. 3.An A1C ≤6.5% may be targeted in some patients with type 2 diabetes to further lower the risk of nephropathy [Grade A, Level 1 (5) ] and retinopathy [Grade A, Level 1 (6) , but this must be balanced against the risk of hypoglycemia [Grade A, Level 1 (5)].
  4. 4.Less stringent A1C targets (7.1%–8.5% in most cases) may be appropriate in patients with type 1 or type 2 diabetes with any of the following [Grade D, Consensus]:
    • a) Limited life expectancy
    • b) High level of functional dependency
    • c) Extensive coronary artery disease at high risk of ischemic events
    • d) Multiple comorbidities
    • e) History of recurrent severe hypoglycemia
    • f) Hypoglycemia unawareness
    • g) Longstanding diabetes for whom it is difficult to achieve an A1C ≤7.0% despite effective doses of multiple antihyperglycemic agents, including intensified basal-bolus insulin therapy
  • 5.In order to achieve an A1C ≤7.0%, people with diabetes should aim for:
    • FPG or preprandial PG target of 4.0–7.0 mmol/L and a 2-hour PPG target of 5.0–10.0 mmol/L [Grade B, Level 2 (2) for type 1; Grade B, Level 2 (1,7) for type 2 diabetes].
    • If an A1C target ≤7.0% cannot be achieved with a PPG target of 5.0–10.0 mmol/L, further PPG lowering to 5.0–8.0 mmol/L should be achieved [Grade D, Consensus, for type 1 diabetes; Grade D, Level 4 (8,9) for type 2 diabetes].

Abbreviations:
A1C, glycated hemoglobin; BG, blood glucose; FPG, fasting plasma glucose; PG, plasma glucose; PPG, postprandial plasma glucose.

References

  1. UKProspective Diabetes Study (UKPDS) Group. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications inpatientswithtype2diabetes (UKPDS33). Lancet1998;352:837e53.
  2. The Diabetes Control and Complications Trial Research Group. The relationship of glycemic exposure (HbA1c) to the risk of development and progression of retinopathy in the Diabetes Control and Complications Trial. Diabetes 1995;44:968e83.
  3. Holman RR, Paul SK, Bethel MA, et al. 10-year follow-up of intensive glucose control in type 2 diabetes. N Engl J Med 2008;359:1577e89.
  4. Nathan DM, Cleary PA, Backlund JY, et al. Intensive diabetes treatment and cardiovascular disease in patients with type 1 diabetes. N Engl J Med 2005;353: 2643e53.
  5. The ADVANCE Collaborative Group. Intensive blood glucose control and vascular outcomes in patients with type 2 diabetes. N Engl J Med 2008;358:2560e72.
  6. The ACCORD Study Group and ACCORD Eye Study Group. Effects of medical therapiesonretinopathy progressionin type 2 diabetes.NEngl JMed 2010;363:233e44.
  7. Ohkubo Y, Kishikawa H, Araki E, et al. Intensive insulin therapy prevents the progression of diabetic microvascular complications in Japanese patients with non-insulin-dependent diabetes mellitus: a randomized prospective 6-year study. Diabetes Res Clin Pract 1995;28:103e17.
  8. Monnier L, Lapinski H, Colette C. Contributions of fasting and postprandial plasma glucose increments to theoverall diurnalhyperglycemia of type 2 diabetic patients: variations with increasing levels of HbA1c. Diabetes Care 2003;26:881e5.
  9. Woerle HHJ, Neumann C, Zschau S, et al. Impact of fasting and postprandial glycemia on overall glycemic control in type 2 diabetes: importance of postprandial glycemia to achieve target HbA1c levels. Diabetes Res Clin Pract 2007; 77:280e5.

 

Reproduced with permission from Canadian Journal of Diabetes © 2013 Canadian Diabetes Association. To cite this article, please refer to For citation.

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