Results from numerous clinical studies have validated the critical nature of maintaining glycemic control to effectively manage diabetes and to avert or mitigate the various health-related complications associated with poorly controlled diabetes. Health experts indicate that monitoring of blood glucose concentrations provides both clinicians and patients with information regarding patterns in fluctuations of blood glucose concentration that occur in response to diet, exercise, medications, and/or pathologic processes, including stress, injury, infections, hormonal changes, and other illnesses associated with blood glucose fluctuations.

The American Diabetes Association (ADA) notes that glycemic control can be evaluated via the hemoglobin A1C measurement (average blood glucose over a 3-month time frame), continuous glucose monitoring (CGM) utilizing time in range (TIR) and/or glucose management indicator (GMI) measurement, and blood glucose meters (BGMs). The 2022 ADA Standards of Medical Care in Diabetes indicates that clinical trials principally utilize the glucose metric A1C to demonstrate the benefits of improved glycemic control.

Individual glucose monitoring, also a valuable tool for diabetes self-management, involves meals, exercise, and medication adjustment, especially in patients taking insulin. The ADA also states that CGM serves an increasingly critical role in the effectiveness and safety of treatment in many patients with type 1 diabetes and in selected patients with type 2 diabetes.  

ADA recommendations for glycemic assessment include the following: Evaluate glycemic status (A1C or other glycemic measurement, such as TIR or GMI) at least two times a year in patients who are meeting treatment goals (and who have stable glycemic control); and evaluate glycemic status at least quarterly and as necessary in patients whose therapy has recently changed and/or who are not meeting glycemic goals.

ADA recommendations regarding goals for blood glucose concentrations should be individualized and based on duration of diabetes, age/life expectancy, comorbid conditions, known cardiovascular disease or advanced microvascular complications, hypoglycemia unawareness, and individual patient considerations.

The ADA also indicates that glycemic targets must be tailored, in the context of shared decision-making, to address individual needs and preferences and to consider characteristics that affect risks and benefits of therapy since this approach will optimize engagement and self-efficacy.

ADA Recommended Glycemic Goals

• An A1C goal of <7% (53 mmol/mol) for many nonpregnant adults without significant hypoglycemia is appropriate.
• If using ambulatory glucose profile (AGP)/GMI to evaluate glycemia, a parallel goal for many nonpregnant adults is TIR of >70% with time below range <4% and time <54 mg/dL <1%.
• On the foundation of provider judgment and patient preference, achievement of lower A1C levels than the goal of 7% may be appropriate and even beneficial if it can be achieved safely without significant hypoglycemia or other adverse effects of treatment.
• Less stringent A1C goals (such as <8% [64 mmol/mol]) may be appropriate for patients with limited life expectancy or when the harms of treatment are greater than the benefits.
• Reevaluate glycemic targets based on the individualized criteria.

ADA Summary of Glycemic Recommendations for Many Nonpregnant Adults With Diabetes

• A1C: <7.0% (53 mmol/mol)
• Preprandial capillary plasma glucose: 80-130 mg/dL (4.4-7.2 mmol/L)
• Peak postprandial capillary plasma glucose: <180 mg/dL (10.0 mmol/L)

ADA BGM Recommendations

• Patients who are on insulin and using BGM should be encouraged to check when appropriate based on their insulin regimen. This may include testing when fasting, prior to meals and snacks, at bedtime, prior to exercise, when low blood glucose is suspected, after treating low blood glucose concentrations until they are normoglycemic, and prior to and while performing critical tasks such as driving.
• Although BGM in patients on noninsulin therapies has not consistently shown clinically significant reductions in A1C, it may be helpful when altering diet, physical activity, and/or medications (particularly medications that can cause hypoglycemia) in conjunction with a treatment adjustment program.

Patients with diabetes should also be counseled about hypoglycemia, warning signs, prevention, and how to manage if a hypoglycemic episode occurs. Since these episodes can sometimes occur abruptly and may cause confusion, patients/caregivers should have a care plan in place so that action can be promptly initiated. The 2022 ADA Standards of Medical Care in Diabetes highlights evidence demonstrating that relaxing glucose targets for a few weeks can enhance hypoglycemia awareness in many patients.

Patient education, adherence to individualized treatment plan, and routine healthcare are integral components to effectively managing diabetes. The selection of a device to measure blood glucose is contingent upon various factors, including an individual’s specific needs, desires, skill level, and availability of devices, including BGMs and CGMs. When initiating use of these devices, it is imperative that patients/caregivers are educated on the proper use of the device as specified by the manufacturer of the selected device. Clinicians should also ensure that patients/caregivers are comfortable using these devices and review any questions and concerns about the recommended testing procedure as well as direct them to the various patient education/support and cost savings programs made available by manufacturers of these devices.

More in-depth information from the 2022 ADA Standards of Medical Care in Diabetes regarding glycemic targets can be found here.

The content contained in this article is for informational purposes only. The content is not intended to be a substitute for professional advice. Reliance on any information provided in this article is solely at your own risk.

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