Help Patients With Diabetes Understand Their Glycemic Goals

You’ll get questions about outpatient A1c or continuous glucose monitoring (CGM) goals for patients admitted with a diabetes complication.

For example, this may come up for patients admitted with ketoacidosis, hypoglycemia, or a diabetes-related foot infection.

Explain that glycemic goals should be individualized...and that a “one-size-fits-all” approach isn’t safe, practical, or recommended.

A1c. Rely on A1c to assess average glucose over 2 to 3 months. Good evidence links meeting A1c goals with better microvascular outcomes.

Expect to see an A1c target below 7% for most people with diabetes and few comorbidities...or possibly less than 6.5% in younger, healthier patients who can safely reach this goal.

But anticipate a relaxed A1c goal for some patients...since risk of hypoglycemia may outweigh benefits of tighter glucose control.

 For example, an A1c under 7.5% to 8% is often the goal for those with multiple comorbidities or long-standing diabetes...or an even looser goal for frail older patients with dementia, nursing home residents, etc.

CGM. If patients use a CGM, focus on key metrics to fill in blanks that A1c doesn’t provide...such as glucose lows, highs, or variability.

Assess the percentage of time CGM is active...it needs to be at least 70% over a 14-day period for CGM metrics to be the most reliable.

Identify the time in range (TIR)...the amount of time patients are in their sweet spot, such as 70 to 180 mg/dL. In this case, the goal TIR is above 70%...if A1c goal is below 7%.

Increase TIR by first reducing time BELOW range...to limit hypoglycemia. A reasonable goal is less than 4% below 70 mg/dL...and avoiding time under 54 mg/dL.

Review glucose variability...to see how widely glucose swings. For example, aim for a coefficient of variation (CV) of 36% or less.

And check the glucose management indicator (GMI). It’s a rough A1c prediction...based on an average of about 14 days of readings. For example, a mean glucose of 175 mg/dL works out to a GMI of 7.5%.

At discharge, educate patients that they can use the GMI for a “sneak peek” of how recent med or lifestyle changes will impact A1c results...if they continue on the same track.

Use our resource, Improving Diabetes Outcomes, for more guidance on tailoring goals.

• Toolbox: Improving Diabetes Outcomes