Metformin is the best medicine to use first for people with type 2 diabetes, a doctors' group says. The American College of Physicians issued the new guidelines February 6. The college is a professional group for doctors of internal medicine. The group's new guidelines say that doctors should first recommend weight loss and regular exercise for people with type 2 diabetes. But if these changes don't control blood sugar, metformin should be the first drug used, the guidelines say. The doctors' group found that it lowers blood sugar the most, with the fewest side effects. Doctors should prescribe a second drug if metformin is not enough. But there's not enough evidence to recommend one specific drug for this second treatment, the guidelines say. Besides its effect on blood sugar, metformin helped to reduce people's risk of heart disease and early death. People with diabetes are more likely than others to die early of heart attack or stroke. HealthDay News wrote about the guidelines.
By Howard LeWine, M.D.
Harvard Medical School
What Is the Doctor's Reaction?
Diet and exercise are the ideal treatments for type 2 diabetes, the most common form of the disease. For some people, losing as few as 10 pounds, combined with 30 minutes of exercise daily, can bring blood sugar levels back into the normal, healthy range.
However, even if the diet and exercise routine is successful at first, most of us don't stay with it. The lost weight has a way of finding its way back home, to our middles.
Several years ago, the American Diabetes Association's guidelines acknowledged this reality. Lifestyle changes to lose weight and get more active are step one in its guidelines. But the association also said that people just diagnosed with type 2 diabetes should start taking metformin right away.
Metformin lowers blood sugar, in part, by decreasing the liver's production of sugar (glucose). Metformin also makes insulin more effective in moving sugar out of the bloodstream and into cells. When this process doesn't work well, it's called insulin resistance. Cells don't let sugar in, so sugar has nowhere to go. Levels in the blood start to climb. Insulin resistance is one of the main features of type 2 diabetes.
The American College of Physicians (ACP) just published its own guidelines for treatment of people with newly diagnosed type 2 diabetes. The ACP says doctors should give people a chance to lower blood sugar with lifestyle changes first. This message reinforces the importance of diet, weight control and exercise. They are the primary and most important treatments for type 2 diabetes.
If blood sugar doesn't get into the normal range after a few months, then the ACP agrees that metformin is the best drug treatment.
Metformin is the first-line medicine for several reasons:
It's effective. It lowers blood sugar levels by about 20%. People don't gain weight when they take it, as they do with some other diabetes pills and insulin injections. It almost never causes blood sugars to get too low (hypoglycemia). It lowers LDL cholesterol a bit and decreases risk of heart attacks in people with diabetes. It's available as a generic, so it's relatively low in cost.
The most common side effects are a metallic taste in the mouth, nausea and diarrhea. The drug also can interfere with the absorption of vitamin B12. Low B12 levels can cause anemia (low red blood cell count), but metformin rarely leads to anemia.
What Changes Can I Make Now?
If you are newly diagnosed with type 2 diabetes, you and your doctor can decide between two treatment options:
Try only lifestyle changes for a few months. Start metformin right away, combined with diet and exercise.
When making the choice, be realistic. Will you really stick with a strict diet and exercise program over the long haul?
If you doubt it, then start the metformin now.
If you think you can do it, there's nothing wrong -- and a lot right -- with first trying a weight-loss program and exercise. You can start metformin later if needed.
With either choice, ask your doctor for help. Discuss what type of exercise program might be best and most successful for you. Meet with a dietician. Be sure to keep the right foods in your house.
If and when you need metformin, start at a very low dose and increase gradually. Any side effects usually are reduced over time.
Some people should avoid metformin. They include people with:
Impaired kidney functionAlcohol abuseSevere liver diseaseAdvanced heart failure
What Can I Expect Looking to the Future?
Scientists will continue to look for other diabetes drugs that work as well as metformin, with few side effects. Some are already in the pipeline. Ideally, they will be even better than metformin to:
Lower blood sugar without raising insulin levels Minimize weight gain and even help with weight lossHelp prevent further health problems from diabetes, such as vision loss and kidney failureDecrease the risk of heart attack and stroke
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