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%, BMI 34, and FBS 7.5 mmol/L. 1, 2
Rationale for Metformin as Initial Therapy
Metformin is the preferred and most cost-effective first-line agent for newly diagnosed type 2 diabetes unless contraindicated or not tolerated. 1, 2
The American Diabetes Association and European Association for the Study of Diabetes position statement explicitly states: "Unless there are prevalent contraindications, metformin is the optimal first-line drug" and should be "initiated at, or soon after, diagnosis." 1
Metformin reduces HbA1c by approximately 1-1.5%, which would bring this patient's HbA1c from 7.9% close to the target of <7%. 2
For patients with obesity (BMI 34), metformin is particularly appropriate as it is weight-neutral or causes modest weight loss, unlike sulfonylureas which cause weight gain. 2
The UKPDS substudy demonstrated that initial treatment with metformin has superior clinical outcomes in overweight/obese adults with less hypoglycemia and weight gain compared to insulin or sulfonylureas. 2
Why Other Options Are Not First-Line
DPP-4 inhibitors are not first-line agents; they are reserved as second-line therapy when metformin alone fails to achieve glycemic targets after 3 months. 1
Liraglutide (GLP-1 receptor agonist) is added as a second agent after metformin, particularly when additional weight loss and cardiovascular benefits are needed, but is not initiated as monotherapy in newly diagnosed patients. 3, 2
Sulfonylureas are second-line options that carry substantial hypoglycemia risk and cause weight gain, making them less desirable than metformin, especially in obese patients. 1, 2
Practical Implementation Algorithm
Start metformin at a low dose (500 mg once or twice daily) and titrate gradually to minimize gastrointestinal side effects, with a target dose of 2000-2500 mg daily. 2, 4
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. 2
Monitor HbA1c every 3 months. If the target HbA1c of <7% is not achieved after 3 months on metformin, add a second agent such as a GLP-1 receptor agonist (preferred for this patient given BMI 34 for additional weight loss benefit) or SGLT2 inhibitor. 3, 2
Critical Caveats
Avoid metformin if the patient has advanced renal insufficiency (GFR <30 mL/min), alcoholism, or conditions predisposing to lactic acidosis. 2
This patient's HbA1c of 7.9% does not warrant starting with combination therapy or insulin, as dual therapy is reserved for HbA1c ≥9% at diagnosis. 1, 3
Gastrointestinal side effects (nausea, diarrhea) are common but typically transient; starting at a low dose and gradual titration improves tolerability. 2
The correct answer is C) Metformin.