First-line therapy in type 2 diabetes

What is the first-line therapy in type 2 diabetes mellitus: metformin as monotherapy or combined treatment with 2 or more oral antidiabetic agents?

Hertzel Gerstein: People with type 2 diabetes present in many different ways. There is never one answer that works for everybody. However, if you look at clinical practice guidelines, in most countries throughout the world they recommend that metformin be used in addition to diet and physical activity as first-line therapy for somebody with type 2 diabetes. There are many people who may only need metformin for their life, and there are other people in whom metformin may not continue to work and they may need other therapies.

The recommendation to use metformin first is based on data from the United Kingdom Prospective Diabetes Study (UKPDS), which was done in newly diagnosed people with type 2 diabetes. In those individuals, metformin compared to conventional therapy reduced glucose levels as well as mortality in cardiovascular events, which is what forms the basis for this recommendation.