IOWA CITY, IA — About 80 million prescriptions are written in the United States each year for metformin. That is primarily because metformin is widely considered first-line pharmacologic treatment for Type 2 diabetes.

A study in Primary Care Diabetes finds, however, that a surprisingly low percentage of veterans diagnosed with the condition are rapidly started on metformin therapy.1

Researchers from the Iowa City VA Healthcare System and colleagues identified veterans with new onset Type 2 diabetes were identified using national VHA data. Retrospective information was obtained from patients with a first hemoglobin A1c of 6.5% or greater (48 mmol/mol) between 2013 and 2018. Included in the analysis also were veterans with at least one additional A1c of less than 6.5% (48 mmol/mol) documented in the three years prior to the A1c diagnostic for diabetes.

Overall, the study included 144,180 veterans with a mean age of 62; most, 88.2%, had index A1c in the range of 6.5-7.4%. Of those, 45,776 (31.7%) were started on metformin within one year of diabetes diagnosis.

The American Diabetes Association recommends that metformin always be initiated at the time Type 2 diabetes is diagnosed unless there are contraindications. It adds that, for many patients, this will be monotherapy in combination with lifestyle modifications. 

The ADA also points out that metformin is effective and safe, is inexpensive and may reduce risk of cardiovascular events and death.

In this study, researchers reported that the median time to metformin initiation was 12 days, and median time to initiation of any anti-hyperglycemic was 11 days. About 16,000 veterans were referred for lifestyle interventions within 90 days.

“Metformin initiation occurred in fewer patients than expected given metformin is a generic, well-tolerated medication recommended as first-line pharmacologic treatment option regardless of A1c,” the authors wrote. “Further studies are needed to assess the barriers of initiating metformin at time of diabetes diagnosis.”


  1. Zenti KJ, Meyer MM, Waterbury NV, Egge JA. Evaluation of the metformin initiation rate in veterans with newly identified Type 2 diabetes. Prim Care Diabetes. 2021 Feb 15:S1751-9918(21)00014-0. doi: 10.1016/j.pcd.2021.01.014. Epub ahead of print. PMID: 33602605.