A1C Goals for Adults with Diabetes

General A1C Target Recommendations

The American Diabetes Association (ADA) recommends a target A1C of <7% for most non-pregnant adults with diabetes to reduce microvascular complications 1, 2
The American College of Physicians (ACP) recommends an A1C target between 7% and 8% for most adults to balance benefits and risks 3
The Veterans Affairs/Department of Defense guidelines recommend a range of A1C 7.0-8.5% for most individuals with established microvascular or macrovascular disease, comorbid conditions, or 5-10 years life expectancy 3

Consider a more stringent A1C goal of <6.5% for patients with short duration of diabetes, treatment with lifestyle modifications or metformin only, long life expectancy, absence of significant cardiovascular disease 1, 3, 4
Consider a less stringent A1C goal of <8% for patients with advanced microvascular or macrovascular complications, extensive comorbid conditions, long-standing diabetes that is difficult to control, or older adults who are frail 1, 3, 4

For older adults with good functional status, few comorbidities, and longer life expectancy (>10 years), a target A1C of approximately 7% is reasonable 4
For frail older patients, those with limited life expectancy (<5 years), or with advanced complications, a target A1C of approximately 8% is appropriate 4

Targeting A1C levels below 7% may increase risk for adverse effects in many patients 3
Hypoglycemia risk is particularly concerning in patients with history of severe hypoglycemia, impaired renal function, or cognitive impairment 4
Consider de-escalation of therapy if A1C falls below 6.5% to reduce risk of adverse events, especially in older adults 4

Perform A1C testing at least twice yearly in patients meeting treatment goals with stable glycemic control 2
Test quarterly in patients whose therapy has changed or who are not meeting glycemic goals 2
Point-of-care testing for A1C provides opportunity for more timely treatment adjustments 1

The ADA recommends initiating metformin therapy along with lifestyle interventions at the time of type 2 diabetes diagnosis, unless metformin is contraindicated 1
For patients not meeting goals, consider therapy intensification with additional agents 1
For patients with severely elevated A1C (>9%), combination therapy options including metformin plus a second agent or insulin should be considered 3

The American College of Physicians recommends an HbA1c target of 6.5% (48 mmol/mol) for patients managed with lifestyle/diet alone or lifestyle/diet plus a single medication not associated with hypoglycemia risk 5
The American College of Physicians recommends an HbA1c target of 7.0% (53 mmol/mol) for patients on medications associated with hypoglycemia, such as sulfonylureas or insulin 5
The American College of Physicians recommends an HbA1c target of 7.0% (53 mmol/mol) for patients requiring treatment intensification when HbA1c rises to ≥7.5% (58 mmol/mol) on monotherapy 5

Patients with impaired awareness of hypoglycemia should have an HbA1c target of 7-8% (or 7.0-8.5%) 5
Patients with a high risk of falls should have an HbA1c target of 7-8% (or 7.0-8.5%) 5
Patients with occupations requiring operation of machinery or driving should have an HbA1c target of 7-8% (or 7.0-8.5%) 5

The American College of Physicians recommends involving patients in target-setting decisions and adjusting goals if efforts to achieve targets impair quality of life or cause adverse effects, with an HbA1c target based on individual patient factors 5
The American College of Physicians recommends balancing microvascular risk reduction against treatment-related harms, with particular attention to hypoglycemia risk in vulnerable populations, when setting HbA1c targets 5