ACP Recommends Metformin As First-Line Type 2 Diabetes Treatment in Updated Guidelines

Although historically underused, metformin is now being reaffirmed as first-line therapy recommendation for type 2 diabetes. The American College of Physicians (ACP) released the updated clinical practice guidelines in the Annals of Internal Medicine.

The guidelines recommend the use of metformin and encourage consideration of 4 class options for oral pharmacologic treatment if a second agent is required. The updated guidelines, published on January 3, come after the emergence of new research and the FDA’s approval of new diabetes drugs.

Despite evidence pointing to its effectiveness, clinicians have avoided prescribing metformin as a diabetes treatment in the past. Previous studies examining metformin use showed low rates of prescribing among providers, and cited provider perceptions of the treatment were inconsistent with current evidence. Lack of educational interventions seemed to contribute to poor rates of prescribing, as well as concerns about lactic acidosis as an adverse effect.

Although many clinicians may already be taking this approach to treating diabetes, the ACP’s updated guidelines reinforce metformin’s benefit in its expanded use. Even so, the new recommendations merely address the oral agents, excluding insulin or glucagon-like peptide-1 receptor agonists. The recommendations also do not account for recent cardiovascular outcome trials tested in 2008 by the FDA, which assessed cardiovascular effects rather than comparative effectiveness.

“Metformin, unless contraindicated, is an effective treatment strategy because it has better effectiveness, is associated with fewer adverse effects, and is cheaper than most other oral medications,” Nitin Damle, MD, MS, MACP, ACP president, said in a statement.

When used in conjunction with lifestyle modification, metformin can be effective in reducing blood glucose levels, decreasing hypoglycemic episodes, and weight loss. The ACP recommends adding sulfonylurea, thiazolidinedione, SGLT-2 inhibitor, or a DPP-4 inhibitor in the case a patient needs a second oral drug to lower blood sugar levels.

The ACP recommends that selecting metformin as an appropriate therapy for patients with diabetes should be based on discussion of benefits, adverse effects, and costs of add-on medications.

Reference

Qaseem A, Barry MJ, Humphrey LL, Forciea MA, for the Clinical Guidelines Committee of the American College of Physicians. Oral Pharmacologic Treatment of Type 2 Diabetes Mellitus: A Clinical Practice Guideline Update From the American College of Physicians. Ann Intern Med. 2017; doi: 10.7326/M16-1860.