Should metformin remain the first-line therapy in type 2 diabetes mellitus?
Victor M. Montori: It is very difficult to speak today of first-line, second-line, third-line therapies for diabetes because it assumes that somebody is making judgements about the benefits, and harms, and cost, and inconveniences of the different medications. By declaring that metformin should be first-line therapy, we are basically saying that compared with other diabetes medications metformin has the most benefit with the lowest cost and the lowest inconvenience. I think that is true for many, many patients and to that extent it is probably true for many patients that metformin probably should continue to be first-line.
However, there are intriguing findings for newer medications that would suggest that perhaps they contribute to lowering mortality. Some of them also contribute to losing weight and lowering blood pressure. It may be intriguing in the future to see whether medications that can achieve more than one of the patient goals could position themselves in first-line therapy.
For now, those medications are very expensive, at least where I work. That makes it, for me and for my patients, very difficult to think of them early on in the course of treatment of diabetes.