Should A1C Targets Be Individualized for All People With Diabetes?

D iabetes guidelines and organizations typically advocate a target glycated hemoglobin (A1C) value of 6.5– 7.0% but highlight that glycemicmanagement must be individualized. Whereas individualization of both glycemic targets and management is appealing to the clinician as a way of potentially maximizing benefit while minimizing risk, there is little evidence that such an approach will bring more patients to target. It may be argued that this approach could contribute to fewer patients attaining optimal glycemic targets. Nonetheless, the results of recent large outcome trials clearly highlight the fact that individual glycemic target achievement varied markedly, with some patients apparently deriving more clinical benefit and others deriving more harm. At the same time, there is ongoing evidence of a treatment gap in many surveys of clinical practice and a suggestion that algorithm-driven protocols may be more effective. Collectively, therefore, the currently available evidence suggests that algorithm-driven protocols that incorporate individualized targets based on patient characteristics designed to preserve a sound balance between the benefits and risk of good glycemic control may be an appropriate way of getting more patients to target in a safe and effective manner. Over 280 million people worldwide are known to have diabetes (1), and this number is projected to grow to 438million by 2030 (2). Current diabetes treatment guidelines (3–9) encourage a multifaceted therapeutic approach (10,11). Central to these recommendations is early diagnosis and active intervention to realize and maintain glycemic control, with the aim of stopping the development of microvascular complications, reducing the risk of macrovascular events, and ameliorating the symptoms of acute hyperglycemia (7,10–17). The prognostic significance of A1C in regard to the incidence of diabetes complications, and the risk reductions associated with improvements in A1C, have been documented in both type 1 (12,18) and type 2 (14–16,19) diabetes. These have led to the underscoring of the importance of A1C target achievement. Many organizations around the world including the American Association of Clinical Endocrinologists, the American Diabetes Association (ADA), the Canadian Diabetes Association, the European Association for the Study of Diabetes, the International Diabetes Federation, and the U.K. National Institute for Clinical Excellence currently advocate a general target level for A1C of 6.5–7.0% (3–9). They also all say that the targets of therapy must be individualized. Recently, a joint position statement from the American College of Cardiology, ADA, and the American Heart Association released in response to the premature discontinuation of the glycemic intervention in the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial (20) recommended that although an appropriate A1C target is generally ,7.0%, individualized glycemic targets may be appropriate for some patients. For example, they stated that higher A1C targets may be more appropriate for those patients who are older, have longer duration of diabetes, have a history of severe hypoglycemia, exhibit advanced microvascular ormacrovascular complications, or present with extensive comorbidities. Others have noted that where glucose control closer to normal, or in the normal range, is easily attained, the care necessary to achieve it should be offered to the individual concerned (8). The purpose of this article is to summarize the arguments made for and against target A1C individualization during a formal debate at the 3rd World Congress on Controversies to Consensus in Diabetes, Obesity, and Hypertension (CODHy). Given the significance of the topic, this document highlights the salient features of the opposing views while providing unified guidance on this important issue. Individualization of glycemic targets appears to be logical, since it allows the vast majority of patients to derive the benefits of improved glycemic control while minimizing the potential harm. It should be recognized, however, that there is not much evidence that such an approach will bring more patients to target. In fact, it can be argued that in allowing for individualization of A1C goals in a real-world setting, it is possible that paradoxically fewer people overall may achieve their optimal glycemic targets. It may even be contended that the overall evidence for the potential benefits of improved glycemia are similar for most patient groups and that the potential “harm” of improved glycemia can be minimized by appropriate drug choices in c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c