Hemoglobin A1c monitoring in diabetics
For patients with diabetes, check an A1c every 3 months if uncontrolled, every 6 months if controlled. Uncontrolled is defined as A1c greater than or equal to 7 for standard patients or A1c greater than or equal to 8 for patients with reduced life expectancy. Patients with reduced life expectancy include those with age 80 plus or one of the following diagnoses: CKD stage 3 onwards, coronary artery disease, heart failure, cerebrovascular disease, advanced liver disease, or advanced/terminal cancer.
Clinical notes
ADA Standards of Care 2023 recommendation 6.1 states assess glycemic status at least two times a year in patients who are meeting treatment goals (and who have stable glycemic control). Recommendation 6.2 states to assess glycemic status at least quarterly and as needed in patients whose therapy has recently changed and/or who are not meeting glycemic goals. Recommendation 6.5 states an A1c goal for many nonpregnant adults of <7% without significant hypoglycemia is appropriate. DCCT: prospective RCT of intensive vs standard glycemic control (7% vs 9%) in type 1 diabetes showed better glycemic control associated with 50-76% reductions in rates of microvsdcular complications. UKPDS: similar decreased rates of micro Vascular complications in type 2 diabetes. EDIC: followup of DCCT cohorts showed persistence of microvascular benefits over 2 decades despite diminishing glycemic separation between groups over time. Recommendation 6.7 = less stringent A1c goals (such as < 8%) may be appropriate for patients with limited life expectancy or where the harms of treatment are greater than the benefits. ACCORD: increased mortality seen in intensive vs standard treatment arm, risks may outweigh benefits in higher-risk individuals. See ADA Standards of Care 2023 Figure 6.2 for broad construct for individualizing A1c goals.
