How to Set Individual Treatment Goals for Type 2 Diabetes?
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.
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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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