Mr. Wang flipped through the new edition of the diabetes prevention and treatment guidelines and said to the doctor, "I've been taking metformin for ten years, and I heard its status is in jeopardy?"

The 2024 newly released "Chinese Guidelines for the Prevention and Treatment of Diabetes" indeed indicates some subtle changes in the therapeutic status of metformin. For patients with type 2 diabetes mellitus who also have atherosclerotic cardiovascular disease, heart failure, or chronic kidney disease, the guidelines recommend prioritizing the use of GLP-1 receptor agonists or SGLT2 inhibitors.

However, this does not mean that metformin is exiting the historical stage. It remains one of the foundational and first-line medications for controlling hyperglycemia, especially for patients with type 2 diabetes who do not have these complications.

01 Guideline Status, Changes and Unchanged Aspects of Metformin

The adjustments in the new guidelines reflect the advancement in diabetes treatment philosophy—shifting from merely lowering blood sugar to comprehensive protection of the heart and kidneys. However, this change does not apply to all diabetic patients.

For patients newly diagnosed without cardiovascular and renal complications, metformin remains the preferred initial treatment drug. Even for patients requiring combination therapy, it is often used as a foundational medication in combination with other drugs.

It is noteworthy that the guideline-recommended adjustments primarily target specific high-risk populations. For the majority of ordinary patients with type 2 diabetes, metformin remains a cost-effective option.

02 Five Misconceptions, The Truth About Metformin

Liver damage?In fact, metformin does not undergo hepatic metabolism after entering the human body. Instead, it directly enters the bloodstream and is excreted unchanged in the urine. It primarily acts in the liver and muscles, reducing hepatic gluconeogenesis and increasing glucose utilization in muscles.

Kidney damage?Metformin is indeed excreted through the kidneys, but it does not cause kidney damage in individuals with normal renal function. For patients with pre-existing renal insufficiency, metformin may accumulate due to slowed excretion, increasing the risk of adverse reactions.

Does Price Determine Efficacy?Metformin available on the market includes both original and generic drugs. Products that have passed the "Generic Drug Consistency Evaluation" have their safety and efficacy verified. Products from different manufacturers may have slight differences in absorption and efficacy, but all remain within the scope of national regulatory oversight.

Are side effects terrifying?The most common side effect of metformin is gastrointestinal reactions, with approximately 20% of individuals experiencing symptoms such as nausea, vomiting, and diarrhea during the initial phase of treatment. These reactions typically resolve on their own within a few weeks. Long-term use may affect vitamin B12 absorption, but this can be managed through regular monitoring and supplementation.

High risk of lactic acidosis?With proper attention to contraindications, metformin does not increase the risk of lactic acidosis. For patients with normal liver and kidney function and no hypoxic diseases, it is safe to use as prescribed.

03 Scientific Use, Avoid These Eight Medication Prohibited Zones

Although metformin has a good safety profile, it must be contraindicated or used with caution in certain situations. Understanding these contraindications is crucial for safe medication use.

For patients currently using metformin, it is recommended to check renal function at least once a year. If severe gastrointestinal reactions occur, consider starting with a low dose, taking it with meals, or switching to an extended-release formulation.

04 Long-Term Medication: Two Key Points You Must Know

Patients on long-term metformin therapy require special attention to two issues: gastrointestinal adaptation and nutritional monitoring.

Most patients' gastrointestinal reactions will gradually diminish within a few weeks. If symptoms persist, dose adjustment or a change in drug formulation should be considered under the guidance of a physician.

For vitamin B12 deficiency, it is recommended that patients on medication for more than four years have their vitamin B12 levels checked annually. In daily diet, it is advisable to appropriately increase intake of foods rich in vitamin B12, such as lean meat, seafood, and eggs.

The selection of metformin dosage forms also requires careful consideration: immediate-release tablets and extended-release tablets are recommended to be taken with meals or after meals, while enteric-coated formulations are advised to be taken 30 minutes before meals to minimize gastrointestinal discomfort.

05 Combination Therapy, The New Role of Metformin

Under the framework of the new guidelines, metformin is increasingly being used in combination with other novel glucose-lowering drugs. This combination strategy can address both glycemic control and organ protection.

For patients with comorbid cardiovascular disease, GLP-1 receptor agonists may be added on top of metformin; for patients with comorbid kidney disease, combination with SGLT2 inhibitors may be considered.

This "metformin plus" treatment approach retains the foundational glucose-lowering effect of metformin while providing additional cardiorenal protection through combination therapy. It is important to note that any adjustment to medication regimens should be conducted under the guidance of a professional physician.

After hearing the doctor's detailed explanation, Uncle Wang breathed a sigh of relief: "So I can continue taking my metformin, as long as I have regular liver and kidney function tests." The doctor nodded and wrote a recommendation in his medical record: "Renal function should be reviewed every six months, and vitamin B12 levels should be checked annually."

In the hospital corridor, another diabetic patient hesitantly holds a prescription and asks, "The doctor added a new medication for me. Does that mean metformin is no longer effective?" The doctor patiently explains, "It's not that it's ineffective. Your test results indicate a need for additional heart and kidney protection. Combination therapy can provide you with greater benefits."

Stepping out of the consultation room, the sunlight gently falls on the medication pickup window. The rumors about the "retirement of miracle drugs" are dispelled in the face of professional explanations. Metformin, the seasoned veteran on the battlefield of blood sugar control, continues to safeguard the health defenses of millions of people with diabetes in a more precise role.