Management of Type 2 Diabetes with Metformin

Introduction to Metformin Therapy

Metformin is the first-line agent for patients with type 2 diabetes, including those with normal kidney function, as recommended by the American Diabetes Association 1
Metformin can be safely used in patients with normal eGFR (≥60 mL/min/1.73m²) and is recommended by the National Kidney Foundation 2

The recommended approach is to optimize metformin before adding other agents, as suggested by current guidelines from the American Diabetes Association 1
Metformin has been shown to have cardiovascular benefits and lower mortality compared to other glucose-lowering therapies, according to the European Association for the Study of Diabetes 3

After increasing the metformin dose, monitor for gastrointestinal side effects, changes in fasting and postprandial glucose levels, and any signs of hypoglycemia, especially if combined with basal insulin, as recommended by the Kidney International guidelines 2
Kidney function should be reassessed periodically (at least annually with normal baseline eGFR) 2

Consider adding a GLP-1 receptor agonist, which has cardiovascular benefits and minimal hypoglycemia risk, as suggested by the Kidney International guidelines 2
SGLT2 inhibitors could be considered as they provide cardiovascular and renal protection, according to the Kidney International guidelines 2

Avoid increasing both insulin and metformin simultaneously, as this makes it difficult to attribute effects or side effects to a specific medication change 2
Don't overlook monitoring vitamin B12 levels in patients on long-term metformin therapy (>4 years), as recommended by the Kidney International guidelines 2
Remember to temporarily discontinue metformin during acute illness, procedures with contrast media, or situations that may compromise renal function, as suggested by the European Association for the Study of Diabetes 3