Therapeutic Targets

• HbA1C <7% (estimated average glucose, 154 mg/dl)
• (Pre-meal Blood sugar < 7.2 mmol/L and Post Meal < 10 mmol/L)
• BP <130/80 mmHg for CKD without proteinuria
• LDL-C <100 mg/dL ( LDL 2.6mmol/L)
• Fasting serum TG 1.6 mmol/L
• BMI 18.5–24.9 kg/m2

Metformin

inhibits mitochondrial glycerophosphate dehydrogenase, reducing hepatic gluconeogenesis;

also increases insulin sensitivity, enhances peripheral glucose uptake (by inducing the phosphorylation of GLUT4 enhancer factor), decreases fatty acid oxidation, and decreases absorption of glucose from the GI tract.

• Best initial drug
• No risk of hypoglycemia
• Does not increase obesity

Contraindications to Metformin

• chronic kidney disease: NICE recommend that the dose should be reviewed if the creatinine is > 130 µmol/l (or eGFR < 45 ml/min) and stopped if the creatinine is > 150 µmol/l (or eGFR < 30 ml/min)
• metformin may cause lactic acidosis if taken during a period where there is tissue hypoxia. Examples include a recent myocardial infarction, sepsis, acute kidney injury and severe dehydration; Potentially fatal in renal failure
• iodine-containing x-ray contrast media: examples include peripheral arterial angiography, coronary angiography, intravenous pyelography (IVP); there is an increasing risk of provoking renal impairment due to contrast nephropathy; metformin should be discontinued on the day of the procedure and for 48 hours thereafter
• alcohol abuse is a relative contraindication