Skip to content

Metformin – Should we stop prescribing it in type 2 DM? – Dr. Sanjay Kalra, Endocrinology

  • by

There is little to be said about metformin’s role in the treatment of diabetes. Over the past few years, metformin has become one of the most commonly prescribed oral drugs across the globe. But how long will its popularity last? Why is it so popular? Is it in danger of being replaced?

Good dear friends and welcome to today’s 10 minute cme the management of diabetes has changed a lot in the past two or three decades the newer drugs that we have have changed the way in which we approach the disease they have even changed the way in which we target the disease because of these changes a question keeps on coming up frequently and this question is

Should we continue prescribing metformin in type 2 diabetes why is this question being asked people may wonder about that but when we consider the history of metformin which was discovered in 1922 nearly 100 years ago then the question actually should be how is it that metformin has been continued as a prescription drug for the past so many decades it was in 1922

That the drug was discovered serendipitously in 1929 researchers found out its glucose lowering effects in rabbits and when it was used in human beings for the first time it was not used for diabetes it was used actually for influenza in the philippines researchers in poland again confirmed its antiviral properties and it was after that that dr stern in france

Found out about its anti-diabetic effects it was introduced for diabetes care in 1957 in france the next year it found its way into the united kingdom formulary and it had reached indian shores within a year as well but it took another uh 13 years or so for acceptance in canada and yet another two decades plus for acceptance in the usa but after that metformin

Has become the most commonly prescribed antidipatic drug and one of the most commonly prescribed drugs overall in the world why is it that metformin is so important and why is it that it enjoys so much popularity the reason is its mechanism of action metformin is an insulin sensitizer it acts upon the adipose tissue the skeletal muscle and the liver it also

Acts upon the gut to reduce appetite and to reduce absorption of glucose in fact in many ways it mimics the incritin effect but at the nano level metformin works at the mitochondria where it activates an enzyme known as amp kinase by doing so it acts like a calorie restriction mimetic and exercise mimetic now we all know that the cornerstone of management of

Type 2 diabetes is lifestyle modification which includes calorie restriction and physical activity so if we have a drug which can mimic the benefits of good lifestyle that drug would be welcome and such a drug is metformin now this is why metformin is so popular not only in india but across the world the proof of the pudding lies in its eating and when we see

The clinical effects of metformin we are not surprised it is a very potent glucose lowering drug it is able to control glucose in diabetes and pre-diabetes and diabetes in pregnancy without causing hypoglycemia the safety and tolerability is unparalleled and apart from the glucocentric effects it also has other metabolic benefits it helps prevent weight gain

It improves the status of the cardiovascular health it is safe for the kidney and it has been accepted for use by other specialties as well metformin for example has been studied as a primary preventive therapy for carcinoma colon and an adjuvant therapy for carcinoma breast with all these benefits to its credit why then are we discussing the question should

Metformin continue to be prescribed the reason for this is arrival of new kids on the block new drugs we now have sdl2 inhibitors and glp-1 receptor agonists which have been proven to have cardiovascular safety and cardiovascular benefit these drugs are welcome for use in type 2 diabetes because anything which reduces cardiovascular risk is welcome but we must

Remember that all the trials that have been done using the newer drugs have been done on the basis of current standard of care which includes right at top metformin so in all the trials that we are speaking of metformin has been used by nearly 95 of all participants it stands to reason therefore that newer drugs like sgl twin emitters or glp1ra will complement

Metformin and will not be able to replace it another issue is of sustainability we have been using metformin now for over 60 years there are no major side effects no major tolerability issues and no long term accidents that we have found anywhere in the world there is no proof for the sustainability of sdl2 inhibitors or glp1ra yet another point to consider is

Health economics metformin is perhaps the most economical glucose lowering drug in the world and the newer drugs seem to be the most expensive each and every country in the world has its own national list of essential medicines and in each of these in the endocrinology section metformin is ranked at number one it’s highly unlikely therefore that any new drug will

Be able to replace metformin at best they will be able to complement this wonderful drug but let’s look at the debate from another angle now is metformin safe for everybody is it well tolerated by everybody does it have no side effects at all now the answer to this will be qualified there will be some people who will have gi disturbance even with the smallest

Of metformin doses others may develop vitamin b12 deficiency yet others may not respond to the drug they will have what we call metformin inadequacy for those who have gi intolerance we can try to change the brand of metformin from immediate release to sustained release we can try to use smaller doses of metformin in more frequent administrations for vitamin b

Deficiency we can always supplement and if metformin proves inadequate the beauty is that it can be co-administered or it can be combined with virtually every other class of glucose lowering drugs whether oral or injectable even after all this discussion however there will be some patients where metformin is contraindicated to explain this let me discuss a

Concept known as the metabolic fulcrum metabolism is a balance between anabolism and catabolism in diabetes the average patient who comes to our clinic will be ubolic eu bollock except for glucose metabolism which of course is disturbed there will be many patients who will be maladaptively anabolic they will be overweight obese they will have the stigmata of

Insulin resistance the stigmata of metabolic syndrome so we term these as maladaptive anabolic it is in these patients that metformin is strongly indicated but there will be a small percentage of patients in our clinics who are catabolic these are the ones who are lean and thin malnourished protein energy malnutrition also micronutrient malnutrition they have

Lost a lot of weight they are not able to eat properly or they are not able to absorb properly they may have some form of lada which is latent autoimmune diabetes of adults they may even have pancreatic diabetes which is being misdiagnosed as type 2 diabetes irrespective of whether these patients have uncontrolled type 2 diabetes or lada or pancreatic diabetes the

Drug of choice for them is insulin there would be no point in adding metformin which is a calorie restriction mimetic once we understand the concept of metabolic fulcrum which helps us differentiate metabolic syndrome or predominant insulin resistance from predominant insulin deficiency it becomes very easy for us to plan our treatment in the diabetes clinic

For those with maladaptive anabolism or those in a ubolic state we will continue to prescribe metformin with or without other drugs as required those who are in the catabolic stage and you don’t need any hifi tests to diagnose catabolism you can see it in front of you these patients will need insulin should we stop prescribing metformin in type 2 diabetes the

Answer is no we should continue prescribing we can add others which have other benefits but the benefits of metformin cannot be ignored i am reminded of an editorial that we wrote about eight years ago and what we said was metformin midlife maturity it’s more than 50 years old maiden charm metformin continues to exude a maiden charm which neither persons living

With diabetes nor their health care providers should resist because when we use this drug we are able to help our countrymen and women enjoy better health with this discussion we hope we’ve been able to make things simpler for all of us i hope that this discussion has helped us improve the quality of care that we prescribe to our patients with diabetes wishing

You and your patients all the best for a healthy future

Transcribed from video
Metformin – Should we stop prescribing it in type 2 DM? – Dr. Sanjay Kalra, Endocrinology By 10Min CMEliveBroadcastDetails{isLiveNowfalsestartTimestamp2021-02-05T120011+0000endTimestamp2021-02-05T121137+0000}