Incretin therapy is key as there is a relative deficiency or decreased responsiveness in metabolic syndrome and type 2 DM. With the GIP moiety being added to the GLP-1 intensification will be possible. Patient bye in and diet and exercise adherence will always be critical.

Rybelsus ( it is oral Ozempic Semaglutide ) has come up as a block buster diabetic medicine in both managing diabetes and Obeisty , having phenomenal results that i have been using for the last year or so , well tolerated , insurance coverage getting better and better and great patient satisfaction

You must look at concomitant conditions including CAD. CKD and obesity
GLP1 and SGLT2 work well!

Metformin is cost effective and very efficacious and then will move to other classes dictated by the hba1c

I find that metformin is often prescribed at sub-therapeutic doses, which leaves the patient often frustrated-especially when confronted with GI issues and not great results. It is a very effective drug when used appropriately-I would only use the extended release formulation. Many pharmacies offer metformin at no charge. The newer injectables make excellent add ons, and would depend on cardiac /or kidney issues as to which to prescribe-as well as insurance coverage or patient assist programs.

I also normally start with metformin, and then add a DPP4 fairly quickly (like after 3 months) if their hgba1c isn't controlled still. DPP4s are great, but also the SGLT2 medications also really work well, it's just insurance coverage can be a bear

I usually start with metformin in patients diagnosed with DM or prediabetes. Of course this is after emphasizing of healthy lifestyle as well. Discontinue metformin if patient is not tolerating it, most common side effect is GI related or if with worsening renal function. If patient is on max dose and A1c is not improving (after checking compliance), then consider adding glipizide and/or insulin. If still not improving, consider other options such as GLP -1 agonist.

Thanks for all your wonderful contributions! What has your clinical experience been with metformin intolerance?

I usually do start with metformin and then will a GLP-1 her SGL D2 as the case dictate

I would also start with metformin as long as there are no renal or hepatic contraindications. I have seen significant A1C improvement with GLP-1 receptor agonists and DPP-4. They are generally well-tolerated also

I always start with metformin but if they are still uncontrolled i try to add januvia as soon as possible as long as insurance covers it. There are so many new novel medications that not only work really well to decrease hgbalc but also help with weight loss. Jumping insurance hoops is always an issue though

I always start with meteor in but next choice is either sglt2 or glp1. Factors can been the patients profession, travel, bathroom access. Also, very important is their insurance and cost or coverage of the medication. It can be next best thing to sliced bread, but if they cannot afford it or do not have access to it, it is useless.

I am a firm believer in the GLP-1 class, as the class is well tolerated in most cases. The class also directly affects several key metabolic defects. Efficacy for glycemic control, weight loss and cardiovascular benefit. I use the GLP-1 agonists as soon as possible.

I believe first metformin especially with fear of needles. Always check kidney function , weight BMI and as always their insurance formulary .

you get more from glp1 as far as benefits when adding to metformin

Generally metformin is first line based on long-term safety and low cost that insurance usually requires before other options are used, unless there is contraindication like low egfr. GLP-1 have robust a1c lowering plus weight lowering and possible cardiovascular benefit so I often use them second-line but SGLT-2 inhibitors have excellent a1c lowering as well. They also have data on cardiovascular benefit, slowing of CKD, some mild weight and blood pressure lowering so I often use them second line. DPP-4 only lower a1c by % so I don't use them as much. Insurance and patient preference/cost factors into decision most of the time.

When starting someone on Metformin I evaluate their kidney function and if appropriate begin therapy. Typically I use Metformin ER as there is a lower risk for GI SEs in comparison to the IR version. I will add a GLP-1 agonist in a patient who has obesity, CAD and are an uncontrolled diabetic. I will add an SGLT-2 inhibitor in a patient who has HTN, CHF and obesity. My philosophy of care when determining medication includes 5 factors: Safety, success, SEs, cost and can this medication treat more than one condition (as typically my patients prefer less medication).

Weight, blood pressure, lipids, fear of needles.

Factors include CV status, renal function, weight/BMI
Excellent experience with SGLT2 to help comorbidities plus CHF or GLP1

As much as the Gravity of Diabetes is heavier than ever in USA regretfully for more than reason at the same time there never has been a more exciting and choiceful time to do the pharmaceutical interventions to manage diabetes . Can not overemphasize the need for diet and exercise to manage diabetes which is overlooked in the enthusiasm of adding on the medicine .Metformin does not need to be taken away when adding the medicines it is the cornerstone in managing the insulin resistance Once it has been decided to add a medicine the way I approach if the obesity is the predominant attribute then i choose GLP-1 and if that is not then SGLT-2 inhibitor is my choice ofcourse if there are no contraindication for their use eventually the paths of these meds cross and pts would need both due course of time ,SGLT-2s have been elevated as Cardiac meds for the treatment and prevention of CAD and CHF i think most likley due to the BP reduction and the weight loss effect and in the same context to prevent the progression of the renal disease , Combo of both meds will be avaiable soon . I have seen dramatic improvement in the diabetic control and the weight management and is quite satisfied with them , Insurance coverage all across is better than ever !

Factors include CV status, renal function/Gfr, weight/BMI
Excellent experience with SGLT2 to help comorbidities plus CHF
GLP1 for the above plus MACE data

I don't usually start with metformin unless obese... but if better control needed, depending on HgA1C, may add Steglatro or Jardiance or Precose.....

Generally will add unless patient has strong preference off metformin. Formulary dictates first choice then route, SQ vs oral. Nevere DDP4. Preference for GLP1 since there are hyperresponders. In practice generally patients will need bother GLP1 and SGLT2 so order not huge question most of the time.