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How to Set Individual Treatment Goals for Type 2 Diabetes?

28. 8. 2020

Treatment goals for type 2 diabetes should always be set individually. In practice, this mainly involves an indicator of the success of long-term compensation – glycated hemoglobin (HbA1c). Recommendations for the diagnosis and treatment of diabetes for general practitioners from 2020 list different target HbA1c values according to the risk of hypoglycemia and other parameters. They also recall different target values for fit, frail, and dependent seniors.

Target HbA1c values based on the risk of hypoglycemia

The risk of hypoglycemia in type 2 diabetics increases with the treatment of insulin and sulfonylurea derivatives, advanced age, duration of diabetes, liver and kidney insufficiency, irregular eating or physical exertion, malnutrition (e.g., in oncological diseases), alcohol consumption, cognitive impairment, or depression. Clinical studies show that the patient’s individual target HbA1c value should be derived from their risk of hypoglycemia.

Table 1  Target HbA1c values based on the risk of hypoglycemia in type 2 diabetics

Risk of hypoglycemia

Target HbA1c value

low

≤ 45 mmol/mol

medium

≤ 53 mmol/mol

high

54–60 mmol/mol

frail patients

around 70 mmol/mol

Other factors influencing the target HbA1c value

Less strict glycemic compensation (i.e., higher target HbA1c value) is suitable not only for patients with a higher risk of hypoglycemia but also for less motivated, non-cooperative, and non-self-sufficient patients, with long-term diabetes, short life expectancy, significant comorbidities, and severe vascular complications of diabetes.

Target HbA1c values in seniors

For older patients with type 2 diabetes, a compromise should be sought between the risk of progression of microvascular and macrovascular complications of diabetes and the risk of hypoglycemia when choosing the target glycemic compensation.

Table 2  Target HbA1c values in diabetic seniors

Type of patient

Characteristics

Target HbA1c value

fit seniors

cooperative, motivated, with low risk of adverse events, with short-term diabetes, without cardiovascular complications, without hypoglycemia

≤ 45 mmol/mol

frail seniors

with severe comorbidities, limited life prognosis, limited self-sufficiency

≤ 60 mmol/mol

dependent seniors

non-self-sufficient, immobile, with severe hypoglycemia in history, very poor life prognosis, with advanced complications and comorbidities, non-cooperative

≤ 70 mmol/mol

In frail older patients, we often encounter conditions or situations where HbA1c value is not a suitable indicator of compensation. In such cases, according to SVL ČLS JEP recommendations, we focus on random blood glucose levels in the range of 6.7–11.1 mmol/l instead of target HbA1c values.

(zza)

Sources:
1. Karen I., Svačina Š. Diabetes mellitus. Novelizace 2020. Recommended diagnostic and therapeutic procedures for general practitioners. Society of General Medicine ČLS JEP, 2020. Available at: www.svl.cz/files/files/Doporucene-postupy/2020/DIABETES-MELLITUS-2020.pdf
2. Karen I., Svačina Š., Jurašková B. Diabetes mellitus. Treatment in elderly patients in the Czech Republic. Novelizace 2019. Society of General Medicine ČLS JEP, 2019. Available at: www.svl.cz/files/files/Doporucene-postupy/2017/DM-u-starsich-pac-2019.pdf



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Authors: Prof. MUDr. Martin Haluzík, DrSc., prof. MUDr. Vojtěch Melenovský, CSc., prof. MUDr. Vladimír Tesař, DrSc.


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