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Frequently Asked Questions for Clinicians

What is the latest evidence for setting safe A1C target goals?

Setting individual A1C targets is discussed in the VA/DoD Clinical Practice Guideline for the Management of Type 2 Diabetes Mellitus in Primary Care, which were last updated in 2017 and can be found here. Glycemic control targets and monitoring begins on page 28 of the Full Guideline and page 35 has a table titled “Determination of average target HbA1C level over time.” This information is also found on page 14 of the Provider Summary.

If my patient is having low blood glucose levels, which medicine should be lowered first: insulin, sulfonylurea, metformin, etc.?

Insulin and sulfonylureas are the medications with the highest risk of hypoglycemia, so should be the initial focus for lowering or discontinuation. While insulin does have a higher risk, the determination of which therapy to modify should always be based on patient-specific factors.

Reference: Malabu, U., Vangaveti, V., & Kennedy, R. (2014). Disease burden evaluation of fall-related events in the elderly due to hypoglycemia and other diabetic complications: a clinical review. Clinical Epidemiology, 6287-294.

My patient’s A1C is low, but the patient reports no low blood glucose readings. What should I do?

  1. Determine how often the patient is checking their blood glucose, as the patient may have stopped routine checks long ago. Also press the patient about any symptoms they may have, as many patients may describe an occasional feeling of being “off”, rather than feeling specific symptoms such as dizziness, lightheadedness, etc.
  2. Make sure the patient is checking their blood glucose at correct intervals (i.e., pre-meal to look for lows)
  3. Consider checking the accuracy of A1C vs. serum monitoring blood glucose (SMBG)
  • A1C tests can have inherent difficulties when the patient has a hemoglobinopathies or other metabolic factors affecting the A1C result, such are uremia or decreases in the life of the red blood cells.
  • Consider checking a fructosamine level. This test does not carry the same information as A1C, but it is also a marker of glucose control over the past 14-30 days and is unaffected by many of the factors that can lead to falsely low A1C.
  • If there is no concern for inaccurate A1C, consider control solution to ensure SMBG are accurate.

References: Smaldone, A., Glycemic Control and Hemoglobinopathy: When A1C May Not Be Reliable. Diabetes Spectrum Volume 21, Number 1, 2008. 46-49. & Schrot, R. J., Patel, K. T. & Foulis, P. Evaluation of Inaccuracies in the Measurement of Glycemia in the Laboratory, by Glucose Meters, and Through Measurement of Hemoglobin A1C Clinical Diabetes April 2007 25:2 43-49.

My patient reports low blood glucose but is unwilling to change their regimen. What do I do?

Many patients with longstanding diabetes may have been last counseled on their treatment years ago. Take the time to explain the risks and benefits to the patient to assure them that individualized A1C goals and diabetes care are the preferred method. If the patient still will not change their medication, make sure they are counseled thoroughly on ways to prevent hypoglycemia as well as the correct management of hypoglycemia and that they have a follow-up visit scheduled. Regardless of a patient’s expressed wishes, clinicians should not feel pressured to prescribe treatment that they believe will be harmful to the patient.

If I back off on insulin or sulfonylurea, should I then consider adding one of the newer agents that does not cause hypoglycemia?

You should first determine what the patient’s A1C target is before evaluating the need for additional agents. Refer to the VA/DoD Clinical Practice guideline.