My patient has had mild diabetes/borderline obesity oriented-insulin resistance for two years. He has also obesity. His insulin production is normal. He is not interested in taking any kind of treatment. He has adopted diet control, but, like many people, cannot maintain 100 percent diet control. Moreover, continual monitoring of his diabetes is not possible. Most of the time, he keeps his sugar normal. His A1c has been between 5.5 to 6.6. Sometimes his blood sugar is 165 mg/dl [9.2 mmol/L] two or three hours after eating. Within four hours, his blood sugar is normal. Can he still go without any medication? One one diabetologist say that he should take SR metformin, while another says that if he takes 1600 calories daily, split into three or four meals, he does not need the metformin. I know that monitoring his blood sugars will tell us which is the better course of action. Which course of action do you recommend?
The decision to use metformin or not to use metformin should be looked at after taking in all the other factors, in addition to blood glucose control. First, if the A1c test you are using has a normal range up to 6.0%, his A1c levels are still elevated above normal. There is no safe level of hyperglycemia. Second, he is obese. Metformin has been shown to help with weight loss. To date, I do not know if he has lost weight. If not, metformin may be even more valuable. Third, type 2 diabetes is not a static disease. It usually follows a story line. He may need additional treatment. The best prevention towards progression of the diabetes is prevention of hyperglycemia. Finally, there may be additional cardioprotective effects from metformin. Metformin, especially taken as the sustained-release preparation, is a convenient drug to take daily. I would recommend he start the metformin.
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