From the Guidelines
Starting metformin for an 82-year-old female with an A1c of 6.7% is generally not recommended. This A1c level is only slightly elevated and falls within what many guidelines consider an appropriate target range for older adults (typically 7-8%) 1. At age 82, the risks of tight glycemic control often outweigh the benefits. Metformin, while generally well-tolerated, can cause gastrointestinal side effects, vitamin B12 deficiency, and rarely lactic acidosis, especially in older patients with declining kidney function.
Key Considerations
- The patient's age and A1c level suggest that the risks of metformin may outweigh the benefits 1
- Lifestyle modifications, including modest dietary changes and light physical activity, are recommended as first-line approaches for older adults with type 2 diabetes 1
- The decision to start metformin should be based on a discussion of benefits and harms, patient preferences, and overall health status, with a focus on maintaining quality of life and avoiding hypoglycemia and medication burden 1
Guidance Statements
- Clinicians should personalize goals for glycemic control in patients with type 2 diabetes, taking into account benefits and harms of pharmacotherapy, patient preferences, and overall health status 1
- Clinicians should aim to achieve an HbA1c level between 7% and 8% in most patients with type 2 diabetes, but consider deintensifying pharmacologic therapy in patients who achieve HbA1c levels less than 6.5% 1
- Clinicians should treat patients with type 2 diabetes to minimize symptoms related to hyperglycemia and avoid targeting an HbA1c level in patients with a life expectancy less than 10 years due to advanced age or chronic conditions 1
From the FDA Drug Label
are older than 80 years If you are over 80 years old you should not take metformin hydrochloride tablets unless your kidneys have been checked and they are normal. The patient is 82 years old, and according to the label, metformin should not be taken unless kidney function has been checked and is normal. Since there is no information provided about the patient's kidney function, it is recommended not to start metformin without first checking kidney function 2.
From the Research
Patient Profile
- Age: 82 years
- A1C level: 6.7
Considerations for Metformin Therapy
- The patient's A1C level is 6.7, which is below the typical threshold for initiating metformin therapy in patients with type 2 diabetes 3
- However, age is a significant independent factor of A1C levels, and A1C levels tend to rise with age 4
- The American Diabetes Association recommends considering the patient's overall health, lifestyle, and preferences when determining the target A1C level
Risks and Benefits of Metformin Therapy
- Metformin is associated with a rare but serious risk of lactic acidosis 5
- The combination of metformin and SGLT2 inhibitors may increase the risk of metabolic acidosis 5
- However, metformin is generally considered a safe and effective treatment for type 2 diabetes, and its benefits may outweigh the risks for many patients
Alternative Treatment Options
- Sulfonylureas may be associated with an increased risk of all-cause mortality and major hypoglycemic episodes compared to other oral hypoglycemic agents 6
- DPP-4 inhibitors and thiazolidinediones may be alternative treatment options for patients who cannot tolerate metformin or require additional glucose-lowering therapy 7