In this case, an otherwise healthy 49-year-old man presents to his primary care physician for
follow-up of a hemoglobin A1c. Three months ago, his hemoglobin A1c was 8.9% on routine screening.
Today, after lifestyle modifications, it is 8.1% and his serum glucose is 270 mg/dL. What is the
best initial therapy for this patient's condition? So here we see a patient who has poorly
controlled diabetes with a very elevated hemoglobin A1c and a serum glucose that is also in
the elevated range. This implies not only is his intermediate and long-term glucose management
poor but so is his short term management. So under these situations, initiation of metformin therapy
taken orally twice a day would be the best recommendation. Let's talk a little bit about metformin
which is a biguanide. It is the best additional therapy for hypoglycemic control at the diagnosis
of type 2 diabetes and in patients without marked hypoglycemia this is measured by serum glucose
which is less than 300 mg/dL or a hemoglobin A1c less than 10%, both criteria that our patient
fits. It has also been shown to decrease major cardiovascular events and metformin is also used in
women who have polycystic ovary syndrome. Metformin is first line therapy in the management
of type 2 diabetes. It's initiated along with lifestyle modifications at the time of diagnosis or
alternatively within 6 weeks of failing to obtain glycemic control with lifestyle changes alone.
Lifestyle changes being exercise and diet. There is a low incidence of hypoglycemia and weight
gain with metformin compared with some of the other oral agents and insulin. The mechanism of action
of metformin is interesting. It increases insulin sensitivity, it decreases hepatic gluconeogenesis,
it increases glycolysis, and causes increased peripheral glucose uptake that can promote weight
loss, which is often desired in patients presenting with type 2 diabetes.