Provider Attitudes Toward Metformin Prescribing | Providers (%) | |
---|---|---|
Patient situation 1: uncontrolled T2DM | A 50-year-old patient with controlled diabetes (A1C of 6.3%), is taking metformin 500 mg daily and tolerating it well. What would you do? | |
Keep 500 mg metformin/day | 88 | |
Titrate metformin to a target dose of 1500 mg/day | 5 | |
Titrate metformin to a target dose of 2000 mg/day | 7 | |
Patient situation 2: uncontrolled T2DM | If a 50-year-old patient with uncontrolled diabetes and an A1C of 8.3% is taking metformin 500 mg/day and tolerating it well, which of the following would you be most likely to do? | |
Titrate metformin to a target dose of 1500 mg/day | 11 | |
Titrate metformin to a target dose of 2000 mg/day | 84 | |
Add a sulfonylurea | 3 | |
Add a dipeptidyl-peptidase-4 inhibitor | 2 | |
Patient situation 3: uncontrolled T2DM | If a 50-year-old patient with uncontrolled diabetes and an A1C of 7.3% is taking metformin 1500 mg/day and tolerating it well, which of the following would you be most likely to do? | |
Titrate metformin to a target dose of 2000 mg per day | 75 | |
Add basal insulin | 0 | |
Add a sulfonylurea | 18 | |
Add a dipeptidyl-peptidase-4 (DPP-4) inhibitor | 7 | |
Patient situation 4: chronic kidney disease | For a 50-year-old male patient with chronic kidney disease and diabetes taking metformin 1750 mg/day, at what point would you stop the metformin? | |
When the serum creatinine is >1.5 | 51 | |
When the CKD-EPI eGFR is <60 mL/min | 15 | |
When the CKD-EPI eGFR is <30 mL/min | 33 | |
When the CKD-EPI eGFR is <15 mL/min or the patient is receiving dialysis | 1 | |
I would not stop the metformin | 0 | |
Patient situation 5: hepatic dysfunction | For a patient with hepatic dysfunction and diabetes taking metformin 1750 mg/day, at what point would you stop metformin or decrease the dose? (Multiple answers are acceptable) | |
Elevated AST or ALT >3 times the upper limit of normal | 49 | |
Elevated INR >1.5 | 35 | |
Elevated bilirubin >2 | 33 | |
Presence of cirrhosis | 50 | |
Presence of cirrhosis with ascites | 60 | |
Hepatic steatosis present on imaging | 6 | |
I would not change the dose or stop metformin for any of these factors | 27 | |
Patient situation 6: heart failure | For a patient with heart failure and diabetes taking metformin 1750 mg/day, at what point would you stop the metformin or decrease the dose? | |
NYHA class I: symptoms only at activity levels that would limit normal individuals | 1 | |
NYHA class II: symptoms with ordinary exertion | 10 | |
NYHA class III: symptoms with less than ordinary exertion | 32 | |
NYHA class IV: symptoms at rest | 13 | |
I would not change the dose or stop metformin | 44 | |
Patient situation 7: chronic obstructive pulmonary disease | For a patient with COPD and diabetes taking metformin 1750 mg/day, at what point would you stop metformin or decrease the dose? (Multiple answers are acceptable) | |
Mild COPD (FEV1 >80%) | 0 | |
Moderate COPD (FEV1 50% to 80%) | 1 | |
Severe or very severe COPD (FEV1 <50%) | 6 | |
Needing oxygen chronically | 10 | |
I would not change the dose or stop metformin | 89 | |
Patient situation 8: alcohol abuse | For a patient with alcoholism and diabetes taking metformin 1750 mg/day, at what point would you stop metformin or decrease the dose? (Multiple answers are acceptable) | |
If they are dependent on alcohol | 28 | |
If they abuse alcohol | 29 | |
If they consume fewer than 2 drinks/day for men and 1 drink/day for women/elderly | 2 | |
If they consume >4 drinks/day or 14 drinks/week, regardless of sex or age | 25 | |
I would not change the dose or stop metformin | 60 | |
Patient situation 9: history of lactic acidosis | For a 50-year-old patient with an A1C of 8.3% who is not currently taking any diabetes medications, has a remote history of lactic acidosis, and has no other risk factors for lactic acidosis, which one of the following would you do? (Multiple answers are acceptable) | |
Not start metformin | 18 | |
Start metformin only | 25 | |
Start metformin and monitor serum lactic acid | 13 | |
Start metformin at a lower dose than I usually would | 15 | |
Start metformin at a lower dose than I usually would and monitor serum lactic acid | 26 | |
Start a sulfonylurea instead of metformin | 29 | |
Start a diabetes medication other than a sulfonylurea or metformin | 12 | |
Patient situation 10: current lactic acidosis | For a 50-year-old patient with an A1C of 6.3%, who is only taking metformin 1750 mg/day for diabetes and who has a new diagnosis of lactic acidosis, which one of the following would you do acutely? The patient is not going to be admitted to the hospital, and their glycemia remains normal. (Multiple answers are acceptable) | |
Stop metformin only | 54 | |
Stop metformin and switch to a sulfonylurea | 30 | |
Stop metformin and switch to a diabetes medication other than a sulfonylurea or metformin | 22 | |
Lower the metformin dose | 2 | |
Lower the metformin dose and monitor serum lactic acid | 8 | |
Continue metformin | 0 | |
Continue metformin and monitor serum lactic acid | 2 |
* Suggested answers are set in italics. For some questions, more than one answer was suggested, given that the available evidence does not suggest one correct answer.
ALT, alanine aminotransferase; AST, aspartate aminotransferase; CKD-EPI, Chronic Kidney Disease Epidemiology Collaboration Equation; COPD, chronic obstructive pulmonary disease; eGFR, estimate glomerular filtration rate; FEV1, forced expiratory volume in 1 second; INR, international normalized ratio; NYHA, New York Heart Association; T2DM, type 2 diabetes mellitus.