Is an A1c Level Below 7 Always Best for Managing Diabetes?

Q

I’m 75 and have type 2 diabetes, high blood pressure and angina. My doctors are very focused on my blood sugar and want me to bring my A1c level down to seven, but that’s proving really hard! How important is it to try to do that?

Bringing the A1c blood-sugar test result down to 7 or lower is a good goal for young and otherwise healthy people with recently diagnosed diabetes—but it might not be an appropriate goal for you.

I know…it seems counterintuitive not to strive for near-normal blood sugar. The A1c test gives you a picture of your overall blood sugar levels over the previous three months. A normal A1c is between 4.5 and 5.6…prediabetes is 5.7 to 6.4… diabetes is 6.5 or higher. Why not shoot for an A1c as low as possible?

Here’s why: Bringing A1c levels down to 7 or lower in older patients may require an aggressive medication regimen that can trigger dangerous side effects including episodes of low blood sugar—which can be more harmful than a moderately elevated A1c level. And studies show that some older patients may not get the same benefits from tight glucose control, such as reduced risks for kidney or eye disease. So a less stringent A1c goal may be best for you. Depending on overall health (not just the diabetes), some doctors might look at a patient of your age and recommend an A1c goal of 7.5, 8 or possibly even higher.

It’s important to keep in mind, though, that diabetes itself is linked to increased risk for cardiovascular disease. So you’ll want to work closely with your doctor to control other factors besides blood sugar—including your blood pressure and cholesterol levels as well as your angina symptoms. Working with a dietitian or certified diabetes educator to improve your diet and exercise regimen will not only help reduce your A1c but will also benefit your health in general…including your cardiovascular system. Sticking to a good nutrition and physical activity program may also reduce your need for strong medications to reduce your A1c. Your goal should be to achieve your A1c goal with as few medications as possible and at the lowest doses possible.

All FDA-approved medications for type 2 diabetes reduce A1c levels by 0.6 to 1.5 percentage points on average. Patients with type 2 diabetes typically start with metformin, a drug that’s considered safe and effective, doesn’t cause weight gain and might also protect against cardiovascular disease. If metformin alone isn’t enough to reduce your A1c, another drug, such as a sodium-glucose cotransporter 2 (SGLT2) inhibitor or glucagon-like peptide-1 (GLP1) receptor agonist, is added. Some of the newer drugs have been shown to provide cardiovascular protection, which may be beneficial for you. But these drugs are not replacements for statins, other cholesterol-lowering treatments or blood pressure medications that reduce the risk of cardiovascular events.

If your A1c level is 9 or higher even with oral medications, you may need to take injected insulin. Your doctor will guide you, but a common strategy is to start with a low dose of long-acting insulin at bedtime and increase gradually to 30 to 50 units/day (or more), as needed.