Results from numerous clinical studies have validated the critical nature of maintaining glycemic control to effectively manage diabetes and to avert or mitigate the various health-related complications associated with poorly controlled diabetes. Health experts indicate that monitoring of blood glucose concentrations provides both clinicians and patients with information regarding patterns in fluctuations of blood glucose concentration that occur in response to diet, exercise, medications, and/or pathologic processes, including stress, injury, infections, hormonal changes, and other illnesses associated with blood glucose fluctuations.

The American Diabetes Association (ADA) notes that glycemic control can be evaluated via the hemoglobin A1C measurement (average blood glucose over a 3-month time frame), continuous glucose monitoring (CGM) utilizing time in range (TIR) and/or glucose management indicator (GMI) measurement, and blood glucose meters (BGMs). The 2023 ADA Standards of Medical Care in Diabetes indicate that clinical trials principally utilize the glucose metric A1C to demonstrate the benefits of improved glycemic control.

Individual glucose monitoring, also a valuable tool for diabetes self-management, involves meals, exercise, and medication adjustment, especially in patients taking insulin. The ADA also states that CGM serves an increasingly critical role in the effectiveness and safety of treatment in many patients with type 1 diabetes and in selected patients with type 2 diabetes.

ADA recommendations regarding goals for blood glucose concentrations should be individualized and based on the duration of diabetes, age/life expectancy, comorbid conditions, known cardiovascular disease or advanced microvascular complications, hypoglycemia unawareness, and individual patient considerations.

The ADA also indicates that glycemic targets must be tailored, in the context of shared decision-making, to address individual needs and preferences and to consider characteristics that affect risks and benefits of therapy since this approach will optimize engagement and self-efficacy.

Glycemic Assessment

• Assess glycemic status (A1C or other glycemic measurement such as time in range or glucose management indicator) at least two times a year in patients who are meeting treatment goals (and who have stable glycemic control).

• Assess glycemic status at least quarterly and as needed in patients whose therapy has recently changed and/or who are not meeting glycemic goals.

ADA Recommended Glycemic Goals

• An A1C goal of <7% (53 mmol/mol) for many nonpregnant adults without significant hypoglycemia is appropriate.

• If using ambulatory glucose profile (AGP)/GMI to evaluate glycemia, a parallel goal for many nonpregnant adults is TIR of >70% with time below range <4% and time <54 mg/dL <1%.

• On the foundation of provider judgment and patient preference, achievement of lower A1C levels than the goal of 7% may be appropriate and even beneficial if it can be achieved safely without significant hypoglycemia or other adverse effects of treatment.

• Less stringent A1C goals (such as <8% [64 mmol/mol]) may be appropriate for patients with limited life expectancy or when the harms of treatment are greater than the benefits.

• Re-evaluate glycemic targets based on the individualized criteria.

ADA Summary of Glycemic Recommendations for Many Nonpregnant Adults With Diabetes

• A1C: <7.0% (53 mmol/mol)

• Preprandial capillary plasma glucose: 80-130 mg/dL (4.4-7.2 mmol/L)

• Peak postprandial capillary plasma glucose: <180 mg/dL (10.0 mmol/L)

ADA BGM Recommendations

• Individuals with diabetes should be provided with blood glucose monitoring devices as indicated by their circumstances, preferences, and treatment. Individuals using continuous glucose monitoring devices must also have access to blood glucose monitoring at all times.

• Patients who are on insulin and using BGM should be encouraged to check when appropriate based on their insulin regimen. This may include testing when fasting, prior to meals and snacks, at bedtime, prior to exercise, when low blood glucose is suspected, after treating low blood glucose concentrations until they are normoglycemic, and prior to and while performing critical tasks such as driving.

• Healthcare professionals should be aware of the differences in accuracy among BGMs—only meters approved by the FDA (or comparable regulatory agencies for other geographical locations) with proven accuracy should be used, with unexpired strips purchased from a pharmacy or licensed distributor.

• Although BGM in patients on noninsulin therapies has not consistently shown clinically significant reductions in A1C, it may be helpful when altering diet, physical activity, and/or medications (particularly medications that can cause hypoglycemia) in conjunction with a treatment adjustment program.

• Healthcare professionals should be aware of medications and other factors, such as high-dose vitamin C and hypoxemia, which can interfere with glucose meter accuracy and provide clinical management as indicated.

Hypoglycemia

Patients with diabetes should also be counseled about hypoglycemia, warning signs, prevention, and how to manage if a hypoglycemic episode occurs. Since these episodes can sometimes occur abruptly and may cause confusion, patients/caregivers should have a care plan in place so that action can be promptly initiated. The 2023 ADA Standards of Medical Care in Diabetes recommendations include:

• Occurrence and risk for hypoglycemia should be reviewed at every encounter and investigated as indicated. Awareness of hypoglycemia should be considered using validated tools.

• Glucose (approximately 15–20 g) is the preferred treatment for the conscious individual with blood glucose <70 mg/dL (3.9 mmol/L), although any form of carbohydrate that contains glucose may be used. Fifteen minutes after treatment, if blood glucose monitoring (BGM) shows continued hypoglycemia, the treatment should be repeated. Once the BGM or glucose pattern is trending up, the individual should consume a meal or snack to prevent recurrence of hypoglycemia.

• Glucagon should be prescribed for all individuals at increased risk of level 2 or 3 hypoglycemia so that it is available should it be needed. Caregivers, school personnel, or family members providing support to these individuals should know where it is and when and how to administer it. Glucagon administration is not limited to healthcare professionals.

• Hypoglycemia unawareness or one or more episodes of level 3 hypoglycemia should prompt hypoglycemia avoidance education and re-evaluation and adjustment of the treatment plan to decrease hypoglycemia.

• Insulin-treated patients with hypoglycemia unawareness, one level 3 hypoglycemic event, or a pattern of unexplained level 2 hypoglycemia should be advised to raise their glycemic targets to strictly avoid hypoglycemia for at least several weeks to partially reverse hypoglycemia unawareness and reduce risk of future episodes.

• Ongoing assessment of cognitive function is suggested with increased vigilance for hypoglycemia by the clinician, patient, and caregivers if impaired or declining cognition is found.

Patient education, adherence to individualized treatment plan, and routine healthcare are integral components to effectively managing diabetes. The selection of a device to measure blood glucose is contingent upon numerous factors, including an individual’s specific needs, desires, skill level, and availability of devices, including BGMs and CGMs. When initiating use of these devices, it is imperative that patients/caregivers are educated on the proper use of the device as specified by the manufacturer of the selected device. Clinicians should also ensure that patients/caregivers are comfortable using these devices and review any questions and concerns about the recommended testing procedure as well as direct them to the various patient education/support and cost savings programs made available by manufacturers of these devices.

More in-depth information from the 2023 ADA Standards of Medical Care in Diabetes regarding glycemic targets can be found here.

The content contained in this article is for informational purposes only. The content is not intended to be a substitute for professional advice. Reliance on any information provided in this article is solely at your own risk.