Q: What advice should I give patients regarding achievement of glycemic control?

Glucose control is influenced by multiple factors such as treatment plan, diet, activity, stress, and illness. Thus, glycemic targets should be individualized to meet the needs of each patient. Self-monitoring of blood glucose (SMBG) and A1C testing are helpful tools to assess overall glycemic control. Patients who take multiple doses of insulin should perform SMBG before meals and snacks, at bedtime, postprandially on occasion, before exercise or driving, and when they experience hypoglycemia. In combination with the A1C level, SMBG results help the patient and the provider make treatment decisions that impact overall glycemic control. The American Diabetes Association (ADA) (2017) recommends a premeal glucose target of 80 to 130 mg/dL (4.4-7.2 mmol/L) and postprandial glucose target (1-2 hours after the start of a meal) of 180 mg/dL (10.0 mmol/L).

A1C reflects the glucose average over the past 3 months, which is useful in determining whether the patients' glycemic goals are being met. The A1C has strong predictive value for diabetes complications and is recommended at least twice annually for patients with stable glucose control. For patients who have changed therapy or are not meeting goals, A1C testing is recommended quarterly. Although a reasonable goal for A1C levels for adults is 7% (53 mmol/mol), providers may suggest more stringent goals (6.5% [48 mmol/mol]) for certain patients, if it can be reasonably achieved without significant hypoglycemia. Patients in this category could include those who have had diabetes a short period of time, have treatment plans that include lifestyle or metformin only, have a long life expectancy, or those without significant cardiovascular disease. However, for patients with a history of severe hypoglycemia, who have a limited life expectancy, advanced complications or other comorbid conditions, or those who have had diabetes for a long time, a less stringent A1C goal of 8% (64 mmol/mol) may be appropriate. Of course, patient preferences should be considered when developing individualized goals (ADA, 2017).

Hypoglycemia unawareness (diminished autonomic response) or one or more episodes of clinically significant hypoglycemia should trigger reevaluation of the treatment regimen. Moreover, patients treated with insulin who experience hypoglycemia unawareness or an episode of clinically significant hypoglycemia should be advised to raise their glycemic targets for several weeks to partially reverse hypoglycemia unawareness and reduce risk of future episodes. Although clinically significant hypoglycemia (severe cognitive impairment requiring assistance from another person) is identified as 54 mg/dL (3.0 mmol/L) or lower, a glucose value of 70 mg/dL (3.9 mmol/L) or lower is often related to symptomatic hypoglycemia and can be important for therapeutic dose adjustment of glucose-lowering drugs. Therefore, patients should be counseled to treat hypoglycemia with fast-acting carbohydrates if he or she experiences a blood glucose of 70 mg/dL (3.9 mmol/L) or less (ADA, 2017).

Stressful events such as an illness, surgery, or trauma may worsen glucose control and if unaddressed can precipitate a life-threatening condition (diabetic ketoacidosis or nonketotic hyperosmolar state). If patients experience conditions that lead to deterioration in blood glucose control, they should be reminded that more frequent SBGM is warranted (ADA, 2017).

When discussing glycemic control with your patient, stress that glucose monitoring to achieve individualized glucose targets, along with continued self-management support may help improve clinical outcomes (ADA, 2017).

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