Management of Elevated HbA1c in Adults with Diabetes and Hypertriglyceridemia

Establishing the Appropriate HbA1c Target

The American College of Physicians recommends an HbA1c target between 7% and 8% for most adults with type 2 diabetes to balance benefits and risks 1
For patients with a short duration of diabetes, long life expectancy, absence of cardiovascular disease, and no history of severe hypoglycemia, targeting an HbA1c closer to 7.0% is recommended 1, 2
Patients with a history of severe hypoglycemia, advanced microvascular or macrovascular complications, extensive comorbid conditions, limited life expectancy, or older age may accept an HbA1c of 7.5-8.0% 1, 2, 4

When HbA1c rises to 7.5% or higher despite current therapy, intensification of drug treatment is recommended 3
For patients on monotherapy with metformin, adding a second agent is considered, as combination therapy is more effective when HbA1c is >7.5% 5
Metformin plus a DPP-4 inhibitor is expected to reduce HbA1c by 0.6-0.8% from baseline 5

Reassess HbA1c in 3 months after treatment intensification, and consider further treatment intensification if targets are not achieved within 3-6 months 5
Test HbA1c quarterly until glycemic goals are met, and at least twice yearly once stable at target 2

Do not target HbA1c below 7.0% in patients at risk for hypoglycemia, with advanced chronic kidney disease, or who are elderly on insulin 4, 2
Avoid first-generation sulfonylureas entirely in patients with any degree of chronic kidney disease due to prolonged half-lives and hypoglycemia risk 4