Healthy patient with few existing chronic illnesses, intact cognitive and functional status, and longer remaining life expectancy: Reasonable HbA1c goal <58 mmol/mol; Fasting or preprandial glucose 5–7.2 mmol/L; bedtime glucose 5–8.3 mmol/L; blood pressure <140/80 mmHg; lipids – statin unless contraindicated or not tolerated.
Complex/intermediate patient with multiple coexisting chronic illnesses or 2+ instrumental activities of daily living impairments or mild to moderate cognitive impairment, and intermediate life expectancy, high treatment burden, hypoglycaemia vulnerability and fall risk: Reasonable HbA1c goal <64 mmol/mol; Fasting or preprandial glucose 5–8.3 mmol/L; bedtime glucose 6.1–11.1 mmol/L; blood pressure <140/80 mmHg; lipids – statin unless contraindicated or not tolerated.
Very complex patient/poor health with long term care or end-stage chronic illnesses* or moderate-to-severe cognitive impairment or 2+ ADL dependencies and limited life expectancy making benefits uncertain: reasonable HbA1c goal <69 mmol/mol†; fasting or preprandial glucose 5.5–10 mmol/L; bedtime glucose 5–8.3 mmol/L; blood pressure <150/90 mmHg; lipids – consider likelihood of benefit with statin (secondary prevention more so than primary).
* The presence of a single end-stage chronic illness such as stage 3–4 CHF or oxygen dependent lung disease, CKD requiring dialysis, or uncontrolled metastatic cancer may cause significant symptoms or impairment of functional status and significantly reduce life expectancy.
† A1C of 69 mmol/mol (8.5%) equates to an eAG of ~200 mg/dL. Looser glycaemia targets than this may expose patients to acute risks from glycosuria, dehydration, hyperglycaemic hyperosmolar syndrome, and poor wound healing.
NB. Adaptations to A1C goal from % to mmol/mol were taken from NZSSD (2011) HbA1c conversion tables available here: www.nzssd.org.nz/HbA1c/4.%20HbA1c%20unit%20conversion%20table%20NZSSD%20Sept%202001.pdf.
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