When to use GLP-1 (Glucagon-like peptide-1) versus Metformin (Biguanide) in type 2 diabetes mellitus?

From the Guidelines

GLP-1 Receptor Agonists vs Metformin in Type 2 Diabetes GLP-1 receptor agonists, such as liraglutide (Victoza) 1.2-1.8 mg/day or semaglutide (Ozempic) 0.5-1.0 mg/week, are considered for patients with type 2 diabetes who have inadequate glycemic control on metformin 1000-2000 mg/day, or for those who cannot tolerate metformin due to gastrointestinal side effects 1.

• Key Considerations:
  • GLP-1 receptor agonists may be preferred over metformin in patients with established cardiovascular disease or those at high risk of cardiovascular events, as they have demonstrated cardiovascular benefits 1.
  • The choice between GLP-1 receptor agonists and metformin should be individualized based on patient-specific factors, including renal function, weight, and cost considerations 1.
  • Metformin is generally the preferred initial pharmacologic agent for type 2 diabetes due to its efficacy, safety, and low cost 1.
  • GLP-1 receptor agonists can be added to metformin if patients have not achieved individualized glycemic targets, or if they have established cardiovascular disease or are at high risk of cardiovascular events 1.
• Renal Function:
  • Metformin may accumulate with reduced kidney function and increase the risk for lactic acidosis, although this risk is very low in absolute terms 1.
  • The dose of metformin should be reduced when the estimated glomerular filtration rate (eGFR) is less than 45 mL/min/1.73 m2, or withdrawn when the eGFR is less than 30 mL/min/1.73 m2 or kidney failure develops 1.
• Cardiovascular Benefits:
  • GLP-1 receptor agonists have demonstrated cardiovascular benefits, including reducing major adverse cardiovascular events and cardiovascular mortality 1.
  • SGLT2 inhibitors have also shown cardiovascular benefits, including reducing hospitalization for heart failure and cardiovascular death 1.

From the Research

GLP-1 versus Metformin in Type 2 Diabetes Mellitus

• The decision to use GLP-1 (Glucagon-like peptide-1) versus Metformin (Biguanide) in type 2 diabetes mellitus depends on various factors, including patient characteristics, disease severity, and treatment goals.
• GLP-1 receptor agonists, such as liraglutide, have been shown to be effective in improving glycemic control and promoting weight loss in patients with type 2 diabetes 2.
• In patients with a history of bariatric surgery, GLP-1 receptor agonists may be a suitable option, as they have been found to be effective and well-tolerated in this population 2.
• Metformin, on the other hand, is often recommended as a first-line treatment for type 2 diabetes due to its efficacy, safety, and low cost.
• However, there is limited evidence directly comparing the effectiveness of GLP-1 receptor agonists and Metformin in specific patient populations, such as those with a history of bariatric surgery.
• Further research is needed to determine the optimal treatment strategy for patients with type 2 diabetes mellitus, taking into account individual patient characteristics and treatment goals.