American College of Physicians Now Recommends Metformin For Initial Type 2 Diabetes Treatment

February 21st, 2012

Several years ago the American Diabetes Association recommended diet and exercise as the initial treatment for type 2 diabetes. As well as that might work for most people, it is very difficult to stick with diet and exercise to maintain your blood sugar levels. The ADA acknowledged that reality some time ago and added to their guidelines starting newly diagnosed type 2 diabetes with metformin. (Published site)


The American College of Physicians this past week confirmed the ADA’s recommendation, stating that metformin should be the first drug of choice in oral therapy for type 2 diabetics in those who don’t respond to diet and exercise.


As reported by MedPage Today, the new guidelines also state that there is not enough evidence to recommend any second medication over another. Led by Dr. Amir Aaseem, director of clinical policy at the American College of Physicians, the organization published the guidelines in the current issue of the Annals of Internal Medicine.

“We found that most diabetes medications reduced blood sugar levels to a similar degree,” Qaseem said in a prepared statement. “However, metformin is more effective compared to other type 2 diabetes drugs in reducing blood sugar levels when used alone and in combination with other drugs. In addition, metformin reduces body weight and improves cholesterol profiles.”

The inability to recommend one secondary drug over another was based on a comparison study of the safety and effectiveness of 11 classes of drugs that have been approved for treating high blood sugar. These included TZD (Avandia), sulfonylureas (Glucotrol), DPP-4 inhibitors (Januvia, Tradjenta, Onglyza) and GLP-1 agonists (Byetta). They analyzed the data from studies of these drugs published between 1966 and 2010.

Among other things they found, there is no data to suggest the best time to start taking metformin; an HbA1c target of below 7 percent is a reasonable goal for many patients; and metformin appears to be more effective than the others for reducing HbA1c and also reduced weight and cholesterol. The most common side effects include bloating, fullness and nausea and stomach cramps.

What is interesting about these guidelines is that despite all the advances in the last few years and the addition of several new classes of drugs, when these experts looked at added oral medications after metformin, they found no good evidence showing one was better than another. In fact, they added that the least expensive were the generic sulfonylureas that have been around since first being approved in 1955. They did note side effects of sulfonylureas’ including low blood sugar, bloating, nausea and heartburn tend to be worse when used in combination treatments.

As is often the case with a lot of treatment options it really comes down to what works best for you, providing the best blood sugar control, with the fewest side effects.