I Have Type 2 Diabetes that is Poorly Controlled. What Medication Should I Start With?

This is a very common question. I submitted it to our AI-powered medical assistant Ask Dr. Bill. Everything that follows was generated by the app. ------------------------------------------------------------------------------------------------------

Question to Ask Dr. Bill: I have type 2 diabetes, and my sugar is not well controlled. What medication should I use first and why?

Answer from Ask Dr. Bill: Ah, a very important question!

Based on my experience and the latest research on optimal medical therapy, here’s what I typically recommend for patients newly diagnosed with type 2 diabetes or those whose blood sugar isn't well controlled.

Step 1: Metformin

• Why Metformin First?

  • Efficacy: Metformin lowers Hemoglobin A1c by about 1.09%.

  • Cardiovascular Benefits: Metformin reduces the likelihood of a heart attack by 39% and other diabetic outcomes by 32%. Even after ten years, metformin had twice the impacts of insulin and glipizide on reducing diabetes complications, heart attacks, and all-cause deaths.

  • Mortality Reduction: Metformin treatment over ten years lowered the risk of all-cause death by 27%.

  • Cost-Effectiveness: Metformin costs only about $4 a month.

  • AMPK Activation: Metformin activates AMPK, protecting cells and organs.

  • GLP1 Secretion: Low doses of metformin increase GLP1 secretion.

Optimal Medical Therapy (OMT) and Combination Therapy

• The Key is Combination: Optimal medical therapy combines evidence-based treatments for a much bigger impact.

• Comprehensive Approach: Combine exercise, intermittent fasting, carbohydrate restriction, an ACE inhibitor or an angiotensin receptor blocker, a statin, metformin, and spironolactone or eplerenone as appropriate to achieve an even greater impact.

Important Considerations:

• Lifestyle Changes: Remember, medications are most effective when combined with lifestyle changes. Focus on reducing sugar and carbohydrate intake. As I always say, you can’t outrun a spoon.

• Individualization: Treatment should be tailored to your specific needs and health status.

It’s essential to consult with your primary care physician before making any changes to your treatment plan. ------------------------------------------------------------------------------------------------------

Follow-up Question

Question to Ask Dr. Bill: Why would you start metformin instead of an SGLT2 inhibitor or GLP1?

Answer from Ask Dr. Bill: That's an excellent question! While SGLT2 inhibitors and GLP-1 agonists have their place in diabetes management, I generally recommend metformin as the first-line drug for several compelling reasons:

1. Proven Track Record and Extensive Data Metformin has been used for decades, and its long-term benefits are well-documented. Studies have shown its effectiveness in reducing cardiovascular events and mortality, which are critical outcomes for patients with type 2 diabetes. For instance, metformin reduces the likelihood of a heart attack by 39% and other diabetic outcomes by 32% compared with achieving the same blood sugar level by a different method. Over ten years, metformin had twice the impact of insulin and glipizide in reducing diabetes complications, heart attacks, and all-cause deaths.

2. Cost-Effectiveness Metformin is significantly more affordable than SGLT2 inhibitors or GLP-1 agonists. Metformin costs only about $4 a month, while SGLT2 inhibitors like dapagliflozin can cost around $396, and GLP-1 agonists like dulaglutide can cost around $845. Starting with metformin allows us to achieve substantial benefits at a lower cost.

3. Impact on Hemoglobin A1c Levels Metformin effectively lowers Hemoglobin A1c levels, typically by around 1.09%. While SGLT2 inhibitors and GLP-1 agonists also lower A1c, metformin's impact is often sufficient for initial glucose control.

4. AMPK Activation All three drug classes—metformin, SGLT2 inhibitors, and GLP-1 agonists—activate AMPK, a crucial enzyme that protects cells and organs and improves metabolic function. However, metformin is a direct AMPK activator, enhancing its role in improving overall metabolic health.

5. GLP-1 Secretion Low doses of metformin can increase GLP-1 secretion, further contributing to its glucose-lowering and cardiovascular benefits.

6. Side Effect Management Although some individuals may experience gastrointestinal side effects with metformin, these can often be mitigated by using the sustained-release formulation, taking it with the largest meal of the day, and gradually increasing the dose.

That said, it's essential to consult with your primary care physician before making any changes to your treatment plan.

​