Glycemic Targets in Diabetes

2016 ADA Guideline Recommendations
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Shivani Chaparala M.B.B.S [2]; Tarek Nafee, M.D. [3]

See also Diabetes mellitus type 2 Glycemic control

2016 ADA Standards of Medical Care in Diabetes Guidelines

"1. When prescribed as part of a broader educational context, self-monitoring of blood glucose (SMBG) results may help to guide treatment decisions and/or self-management for patients using less frequent insulin injections B or non- insulin therapies. (Level of Evidence: E)"

"2. When prescribing SMBG, ensure that patients receive ongoing instruction and regular evaluation of SMBG technique, SMBG results, and their ability to use SMBG data to adjust therapy. (Level of Evidence: E)"

"3. Most patients on intensive insulin regimens (multiple-dose insulin or insulin pump therapy) should consider SMBG prior to meals and snacks, occasionally postprandially, at bedtime, prior to exercise, when they suspect low blood glucose, after treating low blood glucose until they are normoglycemic, and prior to critical tasks such as driving. (Level of Evidence: B)"

"4. When used properly, continuous glucose monitoring (CGM) in conjunction with intensive insulin regimens is a useful tool to lower A1C in selected adults (aged ≥ 25 years) with type 1 diabetes. (Level of Evidence: A)"

"5. Although the evidence for A1C lowering is less strong in children, teens, and younger adults, CGM may be helpful in these groups. Success correlates with adherence to ongoing use of the device. (Level of Evidence: B)"

"6. CGM may be a supplemental tool to SMBG in those with hypoglycemia un- awareness and/or frequent hypoglycemic episodes. (Level of Evidence: C)"

"7. Given variable adherence to CGM, assess individual readiness for continuing CGM use prior to prescribing. (Level of Evidence: E)"

"8. When prescribing CGM, robust diabetes education, training, and support are required for optimal CGM implementation and ongoing use. (Level of Evidence: E)"

"9. People who have been successfully using CGM should have continued access after they turn 65 years of age. (Level of Evidence: E)"

A1C TESTING

"1. Perform the A1C test at least two times a year in patients who are meeting treatment goals (and who have stable glycemic control). (Level of Evidence: E)"

"2. Perform the A1C test quarterly in patients whose therapy has changed or who are not meeting glycemic goals. (Level of Evidence: E)"

"3. Point-of-care testing for A1C provides the opportunity for more timely treatment changes (Level of Evidence: E)"

A1C GOALS

"1. A reasonable A1C goal for many nonpregnant adults is <7% (53 mmol/mol) . (Level of Evidence: A)"

"2. Providers might reasonably sug- gest more stringent A1C goals (such as <6.5% [48 mmol/mol]) for selected individual patients if this can be achieved without signif- icant hypoglycemia or other adverse effects of treatment. Appropriate patients might include those with short duration of diabetes, type 2 diabetes treated with lifestyle or metformin only, long life expec- tancy, or no significant cardiovascular disease. (Level of Evidence: C)"

"3. Less stringent A1C goals (such as <8% [64 mmol/mol]) may be appropriate for patients with a history of severe hypoglycemia, limited life expectancy, advanced microvascular or macrovascular complications, extensive comor- bid conditions, or long-standing diabetes in whom the general goal is difficult to attain despite diabetes self-management education, appropriate glucose monitor- ing, and effective doses of multiple glucose-lowering agents including insulin. (Level of Evidence: B)"

HYPOGLYCEMIA

"1. Individuals at risk for hypoglycemia should be asked about symptomatic and asymptomatic hypoglycemia at each encounter. (Level of Evidence: C)"

"2. Glucose (15–20 g) is the preferred treatment for the conscious in- dividual with hypoglycemia, although any form of carbohydrate that contains glucose may be used. Fifteen minutes after treatment, if SMBG shows continued hypoglycemia, the treatment should be repeated. Once SMBG returns to normal, the individual should consume a meal or snack to prevent recurrence of hypoglycemia (Level of Evidence: E)"

"3. Glucagon should be prescribed for all individuals at increased risk of severe hypoglycemia, defined as hypoglycemia requiring assistance, and caregivers, school personnel, or family members of these individuals should be instructed in its administration. Glucagon administration is not limited to health care professionals. (Level of Evidence: E)"

"4. Hypoglycemia unawareness or one or more episodes of severe hypoglycemia should trigger re- evaluation of the treatment regimen. (Level of Evidence: E)"

"5. Insulin-treated patients with hypoglycemia unawareness or an episode of severe hypoglycemia should be advised to raise their glycemic targets to strictly avoid further hypoglycemia for at least several weeks in order to partially reverse hypoglycemia unawareness and reduce risk of future episodes. (Level of Evidence: A)"

"6. Ongoing assessment of cognitive function is suggested with increased vigilance for hypoglycemia by the clinician, patient, and caregivers if low cognition or declining cognition is found. (Level of Evidence: B)"