Preferred Answer: Metformin, low dose: 250 mg bid
Patient receives written instructions that in 2 weeks, if her average blood glucose is above 130 mg/dL, she should increase the metformin dose to 500 mg bid. Two weeks after that, if her average blood glucose is still over 130 mg/dL, she can titrate again to 850 mg bid. The patient can go up to a maximum effective dose of 1000 mg bid.
Twice daily dosing from the start sets up twice a day medication behavior in the patient. This tactic may improve medication compliance, since most patients with diabetes are likely to be titrated to twice daily dosing. Twice daily dosing may also help to reduce the GI side effects that some patients experience with metformin.
Metformin is the oral agent of choice for initiating therapy, per the EASD and ADA consensus algorithm.
Proven drug: expected A1c decrease = 1.5 percentage points
Dose adjustments can be made by phone or self-management every 1-2 weeks.
Helps weight loss
Mild side effects, primarily gastro-intestinal
High success rate. Time to reach goal: 3 months.
The other drugs are not preferred at this stage of therapy because:
Sulfonylureas can cause hypoglycemia, weight gain.
Meglitinides can cause hypoglycemia, weight gain
DPP4 inhibitors are newcomers, and are costly
TZDs can cause edema, weight gain, and are expensive
Exenatide is not approved as first line monotherapy; expensive
Pramlintide (Symlin®) is not approved as first line monotherapy; expensive