What Is the First-Line Treatment for Type 2 Diabetes?

Adjusting your diet and exercising more are usually the first steps to controlling type 2 diabetes. If you still cannot maintain your target blood sugar, your healthcare provider may prescribe medication. Metformin is typically the first-line treatment.

This article discusses metformin, its side effects, and alternative medications used if metformin isn’t an option.

Why Is Metformin the First Choice?

Metformin belongs to a class of medications known as biguanides. It works by controlling blood sugar levels by reducing how much sugar gets absorbed from the food you eat into your system. It also decreases how much sugar is produced by the liver.

The drug was made a first-line therapy because of its ability to lower glucose (sugar) levels in the body, encourage weight loss, and reduce the risk for certain diabetes complications, such as vascular disease, which affects blood vessels. The risk of developing too-low blood sugar, often associated with other types of medication for diabetes, is also less a factor when taking metformin.

Side Effects and Contraindications

While metformin is generally considered safe, some known and common side effects are associated with the medication, including:

• Stomach discomfort such as bloating, gas, indigestion, heartburn, or pain
• Diarrhea and constipation
• Metallic taste in the mouth
• Headaches
• Skin flushing (redness)
• Muscle pains
• Nail changes

Some health conditions and lifestyle factors may prevent a person from being able to take metformin. They include:

• Kidney or liver problems
• Uncontrolled diabetes
• Severe infection
• Recent heart attack or current ongoing treatment for heart failure
• Breathing difficulties
• High alcohol consumption or alcoholism
• Circulation issues
• An upcoming surgery that will require anesthesia or any scan or X-ray procedure that requires the use of a dye

People taking certain medications should also avoid metformin or speak to their healthcare provider before starting metformin therapy. Some drugs that may interact with metformin include:

• Steroids
• Diuretics (water pills)
• Blood pressure medications
• Hormone drugs such as estrogen, progesterone, or birth control pills
• Other diabetic medications
• Antinausea drugs
• Asthma medications
• Medications designed to treat mental health conditions
• Thyroid disease drugs

Metformin may also reduce vitamin B12 levels in the body, so healthcare providers should monitor your B12 stores and have you supplement if necessary when taking the drug. Vitamin B12 is essential for nerve cells and blood health.

Medication Prescribed With Metformin

Metformin is often prescribed with other medications or as a combination medicine to help control diabetes further. Some medications that can be prescribed with metformin include:

• Thiazolidinediones: Medications such as Actos (pioglitazone) and Avandia (rosiglitazone) increase the body’s ability to use insulin and can be prescribed alongside metformin.
• Sodium-glucose co-transporter 2 (SGLT2) inhibitors: Medications such as Invokana (canagliflozin), Xigduo (dapagliflozin), and Glyxambi (empagliflozin) reduce the kidneys' ability to reabsorb sugar from urine, thus, reducing blood sugar.
• Dipeptidyl peptidase-4 (DPP-4) inhibitors: Medications such as Janumet (sitagliptin), Kombiglyze (saxagliptin), Jentadueto (linagliptin), and Kazano (alogliptin) work by blocking an enzyme from destroying the hormone glucagon-like peptide 1 (GLP1). GLP1is used by the body to produce or reduce insulin as needed. When the body destroys this hormone, insulin production becomes imbalanced and can worsen diabetes.

Metformin may also be used alongside other therapies for diabetes, such as insulin therapy, to help better manage the disease when insulin alone is no longer working as it should.

Prognosis

Metformin is a first-line therapy because of its effectiveness and safety. Typically, people who take metformin alongside lifestyle changes such as eating healthier and exercising more can manage their diabetes effectively.

Alternative Medications

While metformin is the most commonly used medication for diabetes, it isn’t the only option. Many other drugs are used to manage the condition. The type of drug used depends on the personal factors of each person with type 2 diabetes.

The drugs mentioned above (thiazolidinediones, SGLT2 inhibitors, and DPP-4 inhibitors) are also options for people who cannot take metformin. Medications that encourage better insulin production may also be used and include sulfonylureas and glinides.

Insulin for Type 2 Diabetes

Insulin isn’t always needed for people with type 2 diabetes and is often reserved for those with type 1. People with type 2 diabetes that have tried other medications but haven’t seen any change in their condition are often good candidates for insulin.

Summary

Metformin is used as first-line therapy for type 2 diabetes because it works to keep blood sugar levels controlled, and it is also safe and well-tolerated. While there is a list of side effects associated with the drug’s use, the most common tend to be gastrointestinal and include diarrhea and other stomach irritations.

While metformin is safe, some people may not be able to take it because of other medications they’re on, health problems such as liver or kidney disease, or if they consume incredibly high levels of alcohol regularly. Heavy alcohol consumption and metformin use can lead to a rare but life-threatening condition known as lactic acidosis.

In some cases, metformin is also prescribed alongside other diabetes drugs for the best results possible. These are referred to as combination drugs and make the condition much more manageable. There are different types of diabetes medications on the market. Still, they are typically used for people who can’t take metformin or have not seen any effective changes after taking the drug.

A Word From Verywell

Having type 2 diabetes isn't always easy. Still, metformin is a well-tolerated and effective drug on the market today that many people with the condition can use to help manage their disease effectively. Using metformin may come with side effects, but since the drug is so effective and reduces the risk of low blood sugar, it's the best option for those with type 2 diabetes.