Diabetes Management

Target Blood Glucose Levels

The target HbA1c level is less than 7.0% for most adults, and 7.0-8.5% for patients with multiple comorbidities or limited life expectancy (5-10 years), as recommended by the American College of Physicians and the VA/DoD guideline 1, 2, 3
For frail elderly patients or those with less than 5 years life expectancy, the American College of Physicians suggests targeting HbA1c levels between 8.0-9.0% 1
The American Diabetes Association recommends A1c targets of <7.0-7.5% for individuals with few coexisting chronic illnesses, and <8.0% for those with multiple coexisting chronic illnesses 3
The correlation between A1C and mean plasma glucose is as follows:

4, 5, 6, 7

An A1C level of ≥ 6.5% on two separate occasions is diagnostic of diabetes, and requires prompt intervention with lifestyle modifications and possibly medication 8, 9, 10

Metformin is recommended as first-line therapy, with a target dose of 2,000 mg daily as tolerated, along with comprehensive lifestyle modifications 11
For patients with metabolically unstable diabetes, basal insulin may be considered while starting or continuing metformin, with a target dose of 0.5 units/kg/day and titration every 2-3 days based on blood glucose monitoring 12
GLP-1 receptor agonists should be considered before insulin initiation, according to the European Association for the Study of Diabetes 13
SGLT2 inhibitors or GLP-1 receptor agonists with proven cardiovascular benefits are preferred for patients with cardiovascular disease (CVD) or high CVD risk 13, 14
Sulfonylureas, especially long-acting ones like glyburide, should be used with caution due to their high hypoglycemia risk, and are contraindicated in older adults 15

At least 30-60 minutes of moderate-to-vigorous physical activity is recommended at least 5 days/week, to help lower A1C 16, 7, 17
Healthy eating patterns with nutrient-dense foods and decreased consumption of calorie-dense, nutrient-poor foods are recommended, with dietary guidance including counseling on consistent carbohydrate intake patterns and emphasizing Mediterranean-style eating patterns rich in monounsaturated and polyunsaturated fats 11, 16, 18, 19
Weight loss is recommended for all overweight or obese individuals who have diabetes, with a 7-10% decrease in excess weight recommended for overweight or obese patients 16, 18, 19

HbA1c should be checked every 3 months until target is reached, and then at least twice yearly if stable, according to the American Diabetes Association and the American College of Physicians 11, 20, 21
Focus on symptoms of hyperglycemia rather than strict numeric targets, especially for patients approaching the age threshold (77 years) or with limited life expectancy 1, 22
Continuous glucose monitoring should be considered for individuals on insulin, especially those with Type 1 diabetes, to reduce hypoglycemia risk 23

Older adults have a greater risk of hypoglycemia than younger adults, which can cause recurrent morbidity and be fatal 23
Abstinence from alcohol is recommended, but for those who continue drinking, limiting to no more than 1 drink/day for women and 2 drinks/day for men is advised, with patients educated about the delayed hypoglycemia risk after drinking alcohol and the importance of glucose monitoring after alcohol consumption 18, 24
When appropriate, the American Diabetes Association recommends not delaying insulin therapy for patients with significantly elevated HbA1c 25