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NICE guidance - glucose control levels

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A target HbA1c should be set between 6.5% (48 mmol/mol) and 7.5% (59 mmol/mol), based on the risk of macrovascular and microvascular complications. In general, the lower target HbA1c is preferred for people at significant risk of macrovascular complications, but higher targets are necessary for those at risk of iatrogenic hypoglycaemia

NICE note that for type 2 diabetes (1):

  • for adults with type 2 diabetes managed either by lifestyle and diet, or by lifestyle and diet combined with a single drug not associated with hypoglycaemia, support the person to aim for an HbA1c level of 48 mmol/mol (6.5%)

    • for adults on a drug associated with hypoglycaemia, support the person to aim for an HbA1c level of 53mmol/mol (7.0%)

  • in adults with type 2 diabetes, if HbA1c levels are not adequately controlled by a single drug and rise to 58 mmol/mol (7.5%) or higher:
    • reinforce advice about diet, lifestyle and adherence to drug treatment and
    • support the person to aim for an HbA1c level of 53mmol/mol (7.0%)
    • and intensify drug treatment

  • consider relaxing the target HbA1c level on a case-by-case basis, with particular consideration for people who are older or frail, for adults with type 2 diabetes:
    • who are unlikely to achieve longer-term risk-reduction benefits, for example, people with a reduced life expectancy
    • for whom tight blood glucose control poses a high risk of the consequences of hypoglycaemia, for example, people who are at risk of falling, people who have impaired awareness of hypoglycaemia, and people who drive or operate machinery as part of their job
    • for whom intensive management would not be appropriate, for example, people with significant comorbidities

  • If adults with type 2 diabetes achieve an HbA1c level that is lower than their target and they are not experiencing hypoglycaemia, encourage them to maintain it. Be aware that there are other possible reasons for a low HbA1c level, for example, deteriorating renal function or sudden weight loss

  • HbA1c lower than target:
    • if adults with type 2 diabetes achieve an HbA1c level that is lower than their target and they are not experiencing hypoglycaemia, encourage them to maintain it. Be aware that there are other possible reasons for a low HbA1c level, for example, deteriorating renal function or sudden weight loss

  • measure the individual's HbA1c levels at:
    • 3-6-monthly intervals (tailored to individual needs) until the blood glucose level is stable on unchanging therapy
    • 6-monthly intervals once the blood glucose level and blood glucose-lowering therapy are stable

NICE note for type 1 diabetes (2):

  • support adults with type 1 diabetes to aim for a target HbA1c level of 48 mmol/ mol (6.5%) or lower, to minimise the risk of long-term vascular complications
  • agree an individualised HbA1c target with each adult with type 1 diabetes, taking into account factors such as the person's daily activities, aspirations, likelihood of complications, comorbidities, occupation and history of hypoglycaemia
  • ensure that aiming for an HbA1c target is not accompanied by problematic hypoglycaemia in adults with type 1 diabetes
  • measure HbA1c levels every 3-6months in adults with type 1 diabetes
  • consider measuring HbA1c levels more often in adults with type 1 diabetes if the person's blood glucose control is suspected to be changing rapidly; for example, if the HbA1c level has risen unexpectedly above a previously sustained target

Notes:

  • If HbA1c monitoring is invalid because of disturbed erythrocyte turnover or abnormal haemoglobin type, estimate trends in blood glucose control using one of the following:

    • fructosamine estimation
    • quality-controlled blood glucose profiles
    • total glycated haemoglobin estimation (if abnormal haemoglobins)

Reference:

Last reviewed 01/2018

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