Help patients succeed with metformin
ACCORDING TO METFORMIN, about 1 in 3 patients with type 2 diabetes who start, stop it within 3 months, but you can improve their odds of success. Metformin is still first-line for most patients based on its established efficacy and safety, possible cardiovascular benefits and low cost. Plus lactic acidosis is extremely rare with metformin and it can be used in patients with eGFR down to 30 mL/min/1.73 m2. But patients are hearing buzz about SGLT2 inhibitors (Jardiance, etc) or GLP-1 agonists (Victoza, etc) for cardiovascular or kidney benefits. Point out that these medications are add-ons to metformin in key diabetes studies. Help patients stick to metformin and start by setting expectations...
Reassure that GI problems (diarrhea, nausea, etc) are usually short-lived, especially when "starting low and going slow". In general, recommend starting with metformin XR (Glucophage XR) 500 mg daily. Explain that metformin XR (Glucophage XR) seems better tolerated than immediate-release (IR) and generics are available.
Advise titrating by 500 mg every 1 to 2 weeks, usually up to 2 g/day. Think of reaching target doses as a marathon, not a sprint. Recommend taking metformin during or right after a meal. If GI side effects are a problem, suggest backing down to the previous dose then trying a dose increase again after about 2 weeks. If that doesn't do the trick, try giving lower doses more often, such as XR tabs BID instead of daily. But keep an eye on adherence.
For patients with trouble swallowing, suggest crushing the immediate-release tabs. Try a different generic metformin if pill odour is a problem, odour varies among products. Educate that metformin helps manage blood sugar, even if patients don't feel different. And explain that sticking with diabetes medications is linked to a lower risk of kidney or nerve damage.
REFERENCES
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Campbell DJT, Campbell DB, Ogundeji Y, Au F, Beall R, Ronksley PE, Quinn AE, Manns BJ, Hemmelgarn BR, Tonelli M, Spackman E. First-line pharmacotherapy for incident type 2 diabetes: Prescription patterns, adherence and associated costs. Diabet Med. 2021 Sep;38(9):e14622. Available at: https://onlinelibrary.wiley.com/doi/10.1111/dme.14622
American Diabetes Association Professional Practice Committee; 9. Pharmacologic Approaches to Glycemic Treatment: Standards of Medical Care in Diabetes—2022. Diabetes Care 1 January 2022; 45 (Supplement_1): S125–S143. Available at: https://doi.org/10.2337/dc22-S009
Bonnet F, Scheen A. Understanding and overcoming metformin gastrointestinal intolerance. Diabetes Obes Metab. 2017 Apr;19(4):473-481. Available at: https://dom-pubs.onlinelibrary.wiley.com/doi/10.1111/dom.12854
Christofides EA. Practical Insights Into Improving Adherence to Metformin Therapy in Patients With Type 2 Diabetes. Clin Diabetes. 2019 Jul;37(3):234-241. Available at: https://diabetesjournals.org/clinical/article/37/3/234/32949/Practical-Insights-Into-Improving-Adherence-to