Diabetes patients will need your help sticking with metformin...since about 1 in 3 patients will have GI problems with it.

We know metformin is our go-to med for type 2s due to well-established safety and efficacy...possible CV benefits...and low cost. Plus it seems safer than previously thought in stable kidney disease.

But GI side effects can lead to poor adherence...impacting glucose control AND Star Ratings.

Be ready to help patients give metformin a fair trial.

Set the stage for what to expect. Explain that GI problems such as diarrhea are usually short-lived...especially with a slow titration.

Recommend starting with 500 mg daily...or even just 250 mg daily for some. Suggest titrating by 250 to 500 mg every 1 or 2 weeks as tolerated.

Advise backing off to the previous dose if GI side effects are a problem...and trying another dose increase after about 2 weeks.

It's okay if it takes weeks or months to reach the target dose of 2 g/day. And don't feel compelled to aim for doses higher than this...they don't lower glucose much more, but may increase GI side effects.

Consider REtitrating if a patient stops metformin for even a couple of days...especially if GI problems occurred when it was started.

Avoid administration pitfalls. For example, suggest taking metformin during or right after a large meal to improve tolerability.

If needed, suggest giving the ER dose BID instead of once daily.

Suggest switching metformin products if needed. Extended-release forms often need less frequent dosing...and seem to cause fewer GI side effects. Plus, some of the ER generics now cost as little as $10/month.

Discourage Glumetza. It's the only metformin ER product without a generic, and it costs about $6700 per month...and that's not a typo. Plus, there's no good evidence any ER product is better tolerated than another.

Also consider a different generic if pill odor is a problem. Odor varies between products...and ER tabs may not smell as bad.