First line treatment for type 2 diabetes: Is it too early to abandon Metformin?

With the sulphonylurea gliclazide and insulin, metformin is part of the triad of antihyperglycaemic agents on the 2019 World Health Organization list of essential medications. In most international guidelines on the management of hyperglycaemia, metformin is the recommended first-line glucose-lowering agent in subjects with type 2 diabetes. The evidence underpinning these recommendations is mainly based on the efficacy results in a small subgroup of the UK Prospective Diabetes Study participants, which showed a reduction in macro- and micro-vascular complications in overweight subjects with newly diagnosed type 2 diabetes randomised to metformin or non-pharmacological (diet) intervention. However, uncertainty persist about its cardiovascular benefits, as confirmed in a recent Cochrane systematic review.