First-Line Treatment for Newly Diagnosed Type 2 Diabetes
Metformin is the first-line treatment for this patient with newly diagnosed type 2 diabetes, HbA1c 7.9%, and BMI 34. 1
Rationale for Metformin Selection
Metformin should be initiated at or soon after diagnosis in combination with lifestyle modifications. 1 The American Diabetes Association explicitly recommends metformin as the preferred initial glucose-lowering medication for most people with type 2 diabetes due to its efficacy (reducing HbA1c by approximately 1-1.5%), safety profile, and low risk of hypoglycemia when used as monotherapy. 1
For this specific patient profile:
The BMI of 34 makes metformin particularly appropriate because it is weight-neutral or associated with modest weight loss, unlike sulfonylureas which cause weight gain. 1
The HbA1c of 7.9% indicates moderate hyperglycemia where metformin monotherapy combined with lifestyle changes is the appropriate starting point, rather than immediately requiring combination therapy. 2
The UKPDS substudy demonstrated that initial treatment with metformin has benefits on clinical outcomes in overweight/obese adults, with less hypoglycemia and weight gain compared to insulin or sulfonylureas. 1
Why Not the Other Options
DPP-4 inhibitors (Option A) are not first-line agents and lack the extensive clinical outcome data and cost-effectiveness profile of metformin. 2
Liraglutide (Option B), while a GLP-1 receptor agonist with proven cardiovascular benefits, is reserved for specific indications including patients with established cardiovascular disease, heart failure, or chronic kidney disease, or as add-on therapy when metformin alone fails to achieve glycemic targets after 3 months. 2, 1 This patient has no indication for bypassing metformin as initial therapy.
Sulfonylureas (Option D) are inferior to metformin because they cause weight gain (problematic with BMI 34), carry higher hypoglycemia risk, and showed worse outcomes in the UKPDS compared to metformin in overweight patients. 1
Implementation Strategy
Start metformin immediately with initial dosing titrated up to 2000-2500 mg daily as tolerated. 1
Initiate lifestyle modifications simultaneously: counsel the patient to lose at least 5% of body weight, prescribe at least 150 minutes/week of moderate physical activity, and limit non-academic screen time to less than 2 hours daily. 1
Monitor HbA1c every 3 months, and if the target is not achieved after 3 months, add a second agent such as a GLP-1 receptor agonist, which would be preferred for additional weight loss and cardiovascular benefits in this patient with obesity. 1
Critical Caveats
Monitor for gastrointestinal side effects with metformin, which are typically transient but can affect adherence. 1
Avoid metformin in patients with advanced renal insufficiency, alcoholism, or conditions predisposing to lactic acidosis. 1
If the patient presented with random glucose ≥250 mg/dL, HbA1c >9%, ketosis, or diabetic ketoacidosis, insulin therapy would be indicated instead, but this patient's HbA1c of 7.9% does not meet these criteria. 1
Answer: C - Metformin