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Official HbA1C Treatment Targets

Grateful

Grateful

Well-Known Member
Messages
1,399
Location
Kent, United Kingdom
Type of diabetes
Type 2
Treatment type
Diet only
After a few weeks perusing this UK-based forum I have got the general impression that therapeutic targets for diabetes patients in the UK may be more stringent than here in America. These are the guidelines of the American Diabetes Association, followed by many doctors:
  • 7% (53) or lower is the general guideline.
  • A more stringent target of 6.5% (48) or lower for those who have:
    • Short diabetes duration
    • Long life expectancy
    • Type 2 diabetes treated with lifestyle or metformin only
    • No significant CVD/vascular complications
  • A more lenient target of 8% (64) or lower for those with:
    • Severe hypoglycemia history
    • Limited life expectancy
    • Advanced microvascular or macrovascular complications
    • Extensive comorbidities
    • Long-term diabetes in whom general A1C targets are difficult to attain
Am I right that these are high (i.e. "lenient") targets by UK standards, and that such levels would cause tut-tutting by NHS doctors and nurses? Or have I got the wrong end of the stick?

By the way, my doctor here in America said he is happy as long as I can achieve the 7% (53) level or lower.

Just to avoid any confusion, I should make clear that the above numbers are therapeutic targets for those who already have diabetes. They are not diabetes diagnosis levels. In America, and I think in the UK as well, a diagnosis of diabetes is when the A1C is 6.5% (48) or higher.
 
Looks like you are about right

"For adults with type 2 diabetes managed either by lifestyle and diet, or by lifestyle and diet combined with a single drug not associated with hypoglycaemia, support the person to aim for an HbA1c level of 48 mmol/mol (6.5%). For adults on a drug associated with hypoglycaemia, support the person to aim for an HbA1c level of 53 mmol/mol (7.0%). [new 2015]"

"In adults with type 2 diabetes, if HbA1c levels are not adequately controlled by a single drug and rise to 58 mmol/mol (7.5%) or higher:

 
Grateful said:
Interesting.

At the "tight control" end of the spectrum, the UK and US recommendations seem to be the same, namely to aim for 6.5% (48) or lower. That is for people controlling T2 with diet, lifestyle and no more than a single drug, as long as that drug does not have hypoglycemia risks.

It is for the other categories that the US standards are "more lenient" and fairly significantly so.
Click to expand...

The overall safety net recommended by NICE in the UK is that the doctor/nurse should treat each patient on an individual basis, and targets agreed between the two of them according to need. There is no point asking a 90 year old to aim for a 48, unless of course he wants to.
 
My NHS Dr hasn’t mentioned a target, I just figure the lower the better!
 
I think these are more markers of when to "intensify drug treatment" as apart from mataformin and diet there are no treatment option that are proven to be worthwhile for someone who is only just into the diabatic range of AC1.

Dr tend to only talk about targets when they think you are not motivated enough, or they need to give you a reasons for more drugs....... Hence most people on this forum with a recent case of Type2 don't get the target talk, as their results are so much beter then doctors expect.
 
David Unwin talks about this often during his introductions. He became so disillusioned with the treatment available to his T2 patients that he actually passed them along to a junior partner at one point. Now his T2s are his favourite patients because he has found a formula that works for the majority of them. Those who do well reach and surpass targets.
 
It is rather interesting that both the U.S. and U.K. guidelines, which are supposed to be followed by doctors, plainly mention the possible option to treat with diet/lifestyle alone. Yet, in both countries, it seems that option is seldom "prescribed" as an initial course of treatment by doctors, for those patients whom it might benefit. Or at least that is the impression I get.

(I will add here, because of things currently going on in other threads: I agree that the diet/lifestyle-only option is not for everyone.)
 
Grateful said:
It is rather interesting that both the U.S. and U.K. guidelines, which are supposed to be followed by doctors, plainly mention the possible option to treat with diet/lifestyle alone. Yet, in both countries, it seems that option is seldom "prescribed" as an initial course of treatment by doctors, for those patients whom it might benefit. Or at least that is the impression I get.
Click to expand...

It is "prescribed", but mostly by doctors who don't believe it will work, at the end of the 7 minutes they are allowed to spend with us, when they tell us we may (or do) have diabetes. I agree with them, the standard NHS "moderate" low fat diet does not work, and they is all most GPs know about.

Remember a doctor is paid a fix amount per person on their “list”, they don’t get paid anymore if they spend more time with you and therefore reduce the NHS drug bill…….
 
I had my DSN in turmoil during my recent review. She suggested that my HbA1c figure of 48 for a type 1 diabetic was too low and that I should be in a constant state of hypoglycemia. She told me to aim for a figure of 57. I smiled and told her no thank you and that I am fine as I am. She got a bit rattled so I gave her a copy of the NICE GUIDELINES which do state that a target of 48 is what tyoe 1 diabetics should be looking to achieve. She didn't appear to like it too much but my own health is my own primary concern. In any case she backed off and hasn't bothered me since.
 
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Most people with Type1 and a HbA1c of 48 would have been in hopical with hybos a few times! I don't think it can be done without controling the peaks to an extend that is not possible using the methods the NHS teach people.
 
David Unwin starts with hope and expecting that people can get good results from life style changes.......

Most doctors no longer treat people, the treat test results and complaints only allowing one complain per apointment, when often its the complete person that needs to be looked at as a whole.....
 
Crystalwand said:
My last hba1c was 52, so I am stuffed, I am being nice
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That'll be 52, going down.....?

I'll probably delete this post later as I've just broken one of my rules, which is not too comment on T1 posts unless I know exactly what I am writing about... and I don't in this case.
Apologises I didn't check @Crystalwand status.
 
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Let's hope, next sometime in December, but thanks for your comment, I let this site know, but also not holding my breath
 
Bluetit1802 said:
The overall safety net recommended by NICE in the UK is that the doctor/nurse should treat each patient on an individual basis, and targets agreed between the two of them according to need. There is no point asking a 90 year old to aim for a 48, unless of course he wants to.
Click to expand...

I agree @Bluetit1802. Individualizing treatment to the unique needs of each person is indeed a best practice. The recently published US Veterans Affairs/Department of Defence (VA/DOD) Guidelines mirror the NICE guidelines in this respect. They both recommend individualized targets based on each patient’s unique circumstances.

Here is the link to the 13 page VA/DOD ‘pocket guide’ for primary care professionals:
https://www.healthquality.va.gov/guidelines/CD/diabetes/DMCPGPocketcardfinal508.pdf

Here is the link to the 160 page VA/DOD Guideline in full:
https://www.healthquality.va.gov/guidelines/CD/diabetes/VADoDDMCPGFinal508.pdf
The following is from page 30:

“The most effective diabetes treatment plan is individualized to the patient. The benefits and risks of therapy are different for each patient, depending upon the individual’s medical, social, psychological status, and personal goals and preferences. Understanding the patient’s goals, lifestyle, and preferences helps the provider and team work collaboratively with the patient to create a personalized diabetes care plan that integrates the patient’s values and preferences into the provider’s assessment of the risk benefit ratio.[26] Thus, the risks of a proposed therapy are balanced against the potential benefits. The partnership between the patient, provider, and healthcare team optimally begins at the time of initial diagnosis. The provider and team should stress that although diabetes is a serious condition, the patient can successfully manage it with attention to medications, diet, and physical activity. The other important part of this initial message is that there are a number of ways that diabetes can be successfully treated and that the best treatment plan is one that meets the patient’s needs and preferences so that the patient will be more likely to take steps to successfully manage his or her diabetes each day. Patients should be encouraged to work with their provider and team to share decision making regarding glycemic targets, therapies, and goals of treatment.[31] Given the limited time available for visits, the healthcare team can gain useful information to help them tailor the risks and benefits of possible treatment plans to the individual patient.

Given these considerations, the Work Group advocates for an individualized approach based on the patient's absolute risk for developing microvascular complications balanced against known comorbidities, projected life expectancy, presence or absence of pre-existing microvascular complications, the risk of polypharmacy with attendant drug-drug interactions, exposure to medications with limited post-marketing experience, the risk of and ability to perceive hypoglycemia, possible benefits to other comorbidities (such as beneficial effects on weight or hypertension), and patient preferences.”​
 
ringi said:
Most people with Type1 and a HbA1c of 48 would have been in hopical with hybos a few times! I don't think it can be done without controling the peaks to an extend that is not possible using the methods the NHS teach people.
Click to expand...
For some type1's that's perfectly possible. Not entirely sure I'm a type1, but I am on mdi, so high risk of hypo yet I've never needed help for a hypo, and the lowest hypo I've had in the last month was 3,2, and that was only once. Last a1c was 42, should be a bit lower right now. I guess I'm lucky in that my diabetes behaves pretty predictable. Problem is that a lot of HCP's believe you have hypo's all the time when you have a nice low a1c. Glad I have the meter to prove otherwise.
 
Grateful said:
It is rather interesting that both the U.S. and U.K. guidelines, which are supposed to be followed by doctors, plainly mention the possible option to treat with diet/lifestyle alone. Yet, in both countries, it seems that option is seldom "prescribed" as an initial course of treatment by doctors, for those patients whom it might benefit. Or at least that is the impression I get.

(I will add here, because of things currently going on in other threads: I agree that the diet/lifestyle-only option is not for everyone.)
Click to expand...

I got it, and that was nearly 4 years ago. My HbA1c was 53. Medication wasn't even mentioned. As that is the highest it has ever been, medication still hasn't been mentioned. I was given the diet and exercise talk, the dietary information being the Eatwell Plate.
 
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