Skill Checkup: A 53-Year-Old Woman Recently Diagnosed With Type 2 Diabetes

Anne L. Peters, MD


December 21, 2022

ADA guidelines state that first-line therapy is contingent upon comorbidities, patient-centered treatment factors, and management needs. Generally, metformin, a biguanide, and comprehensive lifestyle modification are included. The safety and efficacy of metformin have been well established. Metformin reduces basal and postprandial plasma glucose levels. It is available in both an immediate-release form for twice-daily dosing or in an extended-release form for once-daily dosing. Compared with sulfonylureas, first-line metformin has been shown to have beneficial effects on A1c, weight, cardiovascular mortality, and hypoglycemia.

Patients who are on metformin have shown significant improvements in their A1c and lipid profile, particularly when baseline values are abnormally elevated. In addition, metformin is a widely available and inexpensive oral diabetes drug that is weight neutral or causes modest weight loss. It also has a low rate of hypoglycemia when used alone. Long-term follow-up from the UK Prospective Diabetes Study showed that metformin successfully reduced macrovascular disease endpoints in patients who were obese.

In keeping with an individualized approach to medicine, ADA guidelines note that there are clinical scenarios in which metformin alone might not be the ideal first-line regimen for a patient. For example, if this patient's A1c were higher (≥ 1.5% above the glycemic target), consideration of dual combination therapy would be reasonable.


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