Metformin alternatives: What can I take instead of metformin?

Comparison | Precose | Januvia | Victoza | Glucotrol XL | Actos | Natural alternatives | How to switch meds

Metformin is an oral prescription medication used in the treatment of Type 2 diabetes mellitus. It belongs to a class of drugs known as biguanides. Diabetes mellitus affects approximately 34 million people, a significant portion of the American population. It is estimated that another 88 million have prediabetes. Diabetics are likely to have other comorbid conditions such as high blood pressure, high cholesterol, and heart disease. 

There are two types of diabetes, Type 1 and Type 2. Type 2 diabetics have a variety of oral and injectable medications available to treat their hyperglycemia. Long term control of blood sugar is typically measured by a serum lab value known as hemoglobin A1C (HbA1C). 

Metformin is a first-line treatment for Type 2 diabetes management. It is a generally safe, effective, and cost-conscious choice. Metformin works to decrease blood glucose levels by decreasing glucose production by the liver, decreasing glucose absorption in the intestine, and increasing the utilization of glucose in skeletal muscle and adipose tissue. It rarely causes hypoglycemia, or dangerously low blood sugar. 

Metformin is also used in patients with polycystic ovary syndrome to treat the condition’s associated insulin resistance. Unfortunately, not everyone will be a candidate for metformin therapy. Patients with a history of a hypersensitive reaction to metformin or any biguanide can not take metformin. Patients with severe renal impairment also should avoid metformin therapy. For some, the gastrointestinal side effects of metformin are more than they can manage, and they will struggle to be compliant with metformin. While taking the extended-release version of metformin may alleviate some of the GI-associated factors, it may not be enough for a patient to take metformin regularly as prescribed.

What can I take in place of metformin?

Other alternatives to metformin

• Avandia (rosiglitazone)
• Nesina (alogliptin)
• Tanzeum (albiglutide)
• Jardiance (empagliflozin)
• Invokana (canagliflozin)
• Farxiga (dapagliflozin)

Alpha-glucosidase inhibitors: Precose

Precose is an alpha-glucosidase inhibitor which inhibits the conversion of sucrose to fructose and glucose in the small intestine. It also contributes to delayed carbohydrate and digestion and absorption. Precose is really only clinically effective if consuming a diet high in complex carbohydrates.  It must be taken at the beginning of the meal. Precose is an oral tablet formulation available in 25 mg, 50 mg, and 100 mg strengths.

Dipeptidyl peptidase 4 inhibitors: Januvia, Tradjenta, Onglyza, Nesina

Januvia, Tradjenta, and Onglyza belong to a class of drugs known as dipeptidyl peptidase 4 inhibitors (DPP-4 inhibitors). There is a hormone in the gastrointestinal tract known as glucagon-like peptide 1 (GLP-1) which is responsible for augmenting insulin release. It is susceptible to quick breakdown unfortunately, but DPP-4 inhibitors slow the degradation of GLP-1 in the gut allowing for better glucose control through the longer action of GLP-1. There is a low risk of  hypoglycemia. DPP-4 inhibitors are oral tablets taken once daily, and each comes in a variety of strengths.

Glucagon-like peptide-1 receptor agonists (GLP-1 RAs): Victoza, Ozempic, Trulicity, Bydureon Bcise, Tanzeum

GLP-1 RAs have been a significant treatment development in the mission to find the most effective treatment for Type 2 diabetes. These drugs bind to the GLP-1 receptors in the gut to simulate the action of GLP-1 and induce the release of insulin based on glucose presence. They are known to slow gastric emptying and suppress appetite as well preventing post-prandial (after meal) glucose surge. GLP-1 RAs also carry an indication for reducing cardiovascular events such as heart attack, heart failure, and stroke. These drugs are injectable and come in a variety of dosages. Victoza is a once daily injection while Ozempic, Trulicity, and Bydureon Bcise are once weekly injections. Doses are typically increased in a slow titration to curb GI side effects like nausea and diarrhea.

Sulfonylureas: Glucotrol XL, Amaryl, Micronase

Sulfonylureas take action on Type 2 diabetes by stimulating the release of insulin from beta cells of the pancreas. After taking sulfonylureas for an extended period of time, the liver also begins to produce less glucose and there is increased activity at insulin receptors. The risk for severe hypoglycemia with sulfonylureas is greater than many other treatment options available. Sulfonylureas, like Glucotrol XL are oral tablet dosage forms available in multiple strengths. They typically start out with a lower dose given before breakfast and may increase to higher doses given twice daily.

Thiazolidinediones: Actos, Avandia

Thiazolidinediones such as Actos and Avandia bind to receptors in fat cells and promote maturation of fat cells and the deposit of fat into peripheral tissues. Insulin sensitivity is increased by reducing circulating fat complexes. Unfortunately, weight gain and increased peripheral fat mass is a side effect of thiazolidines. Thiazolidines are oral medications given once or twice daily, and they are available in several different strengths. 

Natural alternatives to metformin

All treatment plans for diabetes care should include diet and lifestyle changes. The American Diabetes Association recommends key actions to improve the control of your diabetes. Start with a modest weight loss goal of 5% and continue to go from there. Choose foods with more unsaturated fats like fish and olive oil. Decrease intake of saturated fats like beef and butter. Decreasing carbohydrate intake is important to help gain glycemic control. Exercise is a key component to lifestyle modifications and weight loss. Even modest weight loss can convey significant changes in blood glucose levels. 

There are natural supplements that make claims that they help with blood sugar levels. Products such as berberine, glucocil, and cinsulin make these claims. These supplements are not studied and approved by the Food and Drug Administration (FDA). Supplements do not require the rigorous testing and manufacturing oversight that prescription and over-the-counter medications undergo. Before using these supplements, please discuss them with your healthcare professionals such as your primary care doctor or pharmacist.

How to switch to a metformin alternative

If you feel that metformin is not the right therapeutic choice for your diabetes, start with talking to your physician. Metformin is a first-line therapy because it is highly effective and cost-efficient. Do not stop taking metformin until you have gotten medical advice from your prescriber. Abrupt discontinuation of metformin could lead to hyperglycemia. The only reason to abruptly stop taking metformin would be if you have an allergic reaction.

There are a few reasons why an alternative to metformin will need to be considered. This includes ongoing GI side effects and kidney disease. You should make sure your labs are up to date so that your kidney function can be monitored by your physician. If the decision to switch is made, your physician will go over your options based on your physical findings. Things to consider will be whether or not you are willing to inject your medication, potential common side effects of other treatments, and the current state of your glycemic control. New medications will likely require dose titration and adjustment for a period of time. Keep in mind it may take some time to find the therapy plan that is right for you.