ADA Glycemic Targets: 2023 Recommendations

The 2023 ADA Glycemic Targets Recommendations are summarized here. Achieving glycemic targets is important to delay or prevent diabetes-related complications.

The results of A1C, Fasting Blood Glucose, 2-hours post-prandial glucose, and continuous glucose monitor readings may differ especially in individuals with blood disorders, hemoglobinopathies, pregnancy, and individuals who are taking hematinics (supplements to improve anemia and red cell indices) [Ref].

Glycemic Assessment: ADA 2023 recommendations:

- Assess glycemic status at least twice yearly in patients who meet glycemic targets and have a stable glycemic record.

- Assess glycemic status every three months in patients who have unstable glycemic control, are not meeting glycemic targets, or whose therapy has been changed.

A1C to blood glucose chart:

The A1C-derived average glucose (ADAG) chart is presented here. The data is derived from a large-scale study.

A1C	Blood Glucose (mg/dl)	Blood Glucose (mmol/L)
5	97	5.4
6	126	7
7	154	8.6
8	183	10.2
9	212	11.8
10	240	13.4
11	269	14.9
12	298	16.5

Hypoglycemia and Hyperglycemia have been classified by the ADA as either level 1 or level 2. The table summarizes here the classification of hypoglycemia and hyperglycemia:

Degree of abnormal blood glucose
Level 2 hyperglycemia	TAR: Percentage of readings and time > 250 mg/dl
Level 1 hyperglycemia	TAR: Percentage of readings and time 181- 250 mg/dl
In-range blood glucose	TAR: Percentage of readings and time 70 – 180 mg/dl
Level 1 hypoglycemia	TAR: Percentage of readings and time 54 – 69 mg/dl
Level 2 hypoglycemia	TAR: Percentage of readings and time < 54 mg/dl

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ADA 2023 Glycemic Targets for Non-pregnant Diabetic Individuals:

The glycemic targets in non-pregnant diabetic individuals should be individualized based on multiple factors. These include:

Risk of hypoglycemia
Duration of diabetes
Life expectancy
Comorbid conditions
Established complications
Patient’s preferences
Resource and support system

Risk Factors	More stringent control	Less stringent control
Risks of hypoglycemia	Low	High
Disease duration	Newly diagnosed diabetes	Long-standing diabetes
Life expectancy	Long	Short
Co-morbid conditions	Absent	Severe
Vascular complications	Absent	Severe
Patient’s preferences	Highly motivated	Less motivated
Resources and support	Readily available	Limited

The A1C ADA Target recommendations:

ADA Glycemic Target Recommendations	A1C goal
The A1C goal for most non-pregnant diabetic individuals	<7% without significant hypoglycemia
Ambulatory blood glucose and continuous glucose range	For most individuals: Time Blood glucose in the range: >70% Time below range: <4% Time <54 mg/dl: <1%
Ambulatory blood glucose and continuous glucose range	For elderly frail individuals: Time Blood glucose in the range: >50% Time below range: <1%
Strict control may be acceptable if the patient and the healthcare professional agree	< 7%
Patients with limited life expectancy and risk of hypoglycemia	<8% (64 mmol/mol)

Pharmacologic therapies and lifestyle interventions are intensified if a diabetic individual does not meet the targets.

Other than the A1C, pre-meals, and peak post-meal blood glucose as measured by a glucometer or continuous glucose monitor should be optimized.

A summary of the ADA 2023 recommendations is given in the table below:

Summary of glycemic recommendations for most non-pregnant adults with diabetes
A1C	<7% (53 mmol/mol)
Premeals capillary plasma glucose	80 – 130 mg/dl (4.4 – 7.2 mmol/L)
Peak post-meal capillary plasma glucose	<180 mg/dl (10 mmol/L)

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Management of Hypoglycemia: ADA 2023 recommendations:

Hypoglycemia is a complication of most diabetes drugs. Novel antidiabetic drugs are usually not associated with hypoglycemia.

Diabetes drugs that are associated with hypoglycemia are:

Drugs that are associated with hypoglycemia	Drugs that are not associated with hypoglycemia
Sulfonylurea: Glimepiride, Gliclazide, Glyburide Meglitinides: Repaglinide, Nateglinide Insulin: Rapid-acting Insulin: Glulisine Aspart Lispro Short-acting Insulin: Regular Insulin Intermediate-acting Insulin: NPH insulin Long-acting Insulin: Glargine Detemir Degludec	Metformin SGLT2 inhibitors Empagliflozin, Dapagliflozin, Canagliflozin DPP-IV inhibitors: Sitagliptin, Vildagliptin, Linagliptin GLP-1 analogs: Semaglutide, Dulaglutide, Liraglutide Dual Glp-1 and GIP analog: Tirzepatide

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Hypoglycemia: ADA 2023 recommendations:

Evaluate for the risk of hypoglycemia at every visit using validated tools

If the patient develops hypoglycemia:

15 to 20 gm glucose per oral is the preferred treatment if the blood glucose is < 70 mg/dl.
The treatment may be repeated if hypoglycemia persists after 15 minutes of oral glucose intake.
The individual should consume a snack or take a regular meal once hypoglycemia improves.

If hypoglycemia is severe (level 2 or level 3 hypoglycemia), glucagon should be administered. Glucagon can be administered by care providers, teachers, parents, or anyone at home. Its use is not limited to healthcare providers.

In patients with one or more episodes of hypoglycemia unawareness should prompt the physicians to raise the target blood glucose for that individual.

In addition, the cause of hypoglycemia should be investigated in all patients.

Classification of Hypoglycemia
Level 1 hypoglycemia	Blood glucose between 54 – 69 mg/dl (3 – 3.9 mmol/L)
Level 2 hypoglycemia	Blood Glucose < 54 mg/dl (3 mmol/L)
Level 3 hypoglycemia	Severely symptomatic hypoglycemia when the patient needs assistance to correct hypoglycemia