From the Guidelines
Metformin is the preferred first-line medication for most patients with type 2 diabetes, unless contraindicated, due to its effectiveness in reducing glycemic levels, weight, and cardiovascular risk, as well as its low cost and favorable side effect profile, as supported by the most recent guidelines 1.
Key Considerations
- The management of type 2 diabetes typically begins with lifestyle modifications, including diet, exercise, and weight loss, but often requires medication.
- Metformin works by decreasing liver glucose production and improving insulin sensitivity without causing weight gain or hypoglycemia.
- If metformin alone is insufficient to achieve target blood glucose levels (typically HbA1c <7%), second-line medications are added, considering the individualized glycemic and weight goals, as well as the presence of other metabolic comorbidities and the risk of hypoglycemia 1.
Second-Line Medications
- SGLT-2 inhibitors (like empagliflozin, dapagliflozin) which promote urinary glucose excretion and offer cardiovascular and kidney benefits.
- GLP-1 receptor agonists (like semaglutide, dulaglutide) which increase insulin secretion, reduce glucagon, and promote weight loss.
- DPP-4 inhibitors (sitagliptin), sulfonylureas (glipizide), and insulin therapy are other options depending on patient characteristics, comorbidities, cost considerations, and glycemic targets.
Monitoring and Adjustments
- Regular monitoring of blood glucose levels, kidney function, and HbA1c every 3-6 months is essential to assess treatment efficacy and make necessary adjustments 1.
- A person-centered shared decision-making approach should guide the choice of pharmacologic agents, considering the effects on cardiovascular and renal comorbidities, effectiveness, hypoglycemia risk, impact on weight, cost, and access, as well as individual preferences 1.
From the FDA Drug Label
14 CLINICAL STUDIES 14. 1 Metformin Hydrochloride Tablets Adult Clinical Studies
A double-blind, placebo-controlled, multicenter US clinical trial involving obese patients with type 2 diabetes mellitus whose hyperglycemia was not adequately controlled with dietary management alone (baseline fasting plasma glucose [FPG] of approximately 240 mg/dL) was conducted Patients were treated with metformin hydrochloride tablets (up to 2550 mg/day) or placebo for 29 weeks.
The preferred medication for the management of type 2 diabetes mellitus (T2DM) is metformin.
- Key benefits: Metformin improves glucose tolerance, lowers basal and postprandial plasma glucose, and decreases hepatic glucose production.
- Clinical evidence: Studies have shown that metformin is effective in reducing fasting plasma glucose and HbA1c levels in patients with T2DM 2.
- Dosage: The maximum daily dose of metformin hydrochloride tablets is recommended to be 2550 mg/day 2.
From the Research
Preferred Medications for Type 2 Diabetes Mellitus (T2DM)
The management of T2DM involves various medications, with metformin being a commonly recommended first-line treatment 3, 4, 5. The preferred medications for T2DM can be categorized as follows:
- First-line therapy: Metformin is widely recommended as the first-line pharmacological therapy for T2DM due to its efficacy in lowering blood glucose levels without increasing the risk of hypoglycemia 3, 4, 5.
- Second-line therapy: For patients who do not achieve good glycemic control on metformin, several options are available, including:
- Sodium-glucose cotransporter 2 (SGLT2) inhibitors, such as empagliflozin, which have been shown to be effective in reducing HbA1c levels and have a favorable safety profile 6.
- Glucagon-like peptide 1 receptor agonists (GLP1 RAs), which have been found to reduce cardiovascular events in patients with T2DM 7.
- Dipeptidyl peptidase 4 (DPP4) inhibitors, which are also considered a viable option for second-line therapy 7.
- Sulfonylureas, which are commonly used but may have a higher risk of hypoglycemia and weight gain 5, 7.
- Combination therapy: Combination of metformin with other medications, such as sulfonylureas or insulin, may be effective in achieving glycemic control 3, 5.
Key Considerations
When selecting medications for T2DM, several factors should be considered, including: