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Our easy-to-read fact sheets provide clinicians with reliable information to share with patients and their caregivers. 

A predominant risk factor for type 2 diabetes is being overweight or obese, so weight loss goals while maintaining normal blood sugar levels are very important for some patients. In addition to lifestyle modifications, medications for type 2 diabetes may aid in losing weight.1,2

Obesity

Obesity is defined as a body mass index (BMI) of 30 kg/m2 or higher and is associated with many major health issues including cardiovascular disease, osteoarthritis, and type 2 diabetes. A weight loss of 5% to 15% can improve obesity-related complications.1,2

There are approved medications to help treat obesity, including phentermine (Lomaira®), orlistat (Alli®), topiramate (Trokendi XR®), and naltrexone/bupropion (Contrave®). However, these are not indicated to treat type 2 diabetes.3

Type 2 Diabetes

Type 2 diabetes is a chronic disease due to a progressive loss of insulin secretion and/or increased insulin resistance. As a result, the body’s naturally produced insulin becomes less effective in reducing the amount of sugar in your blood. Excess weight or excess percentage of body fat can cause some degree of insulin resistance. Most, but not all, patients with type 2 diabetes have overweight or obesity.

Different antidiabetic medications work through different mechanisms to help lower blood sugar. Some of these medications also provide additional benefits for patients, including weight loss. The medications with weight loss benefits include metformin, sodium-glucose cotransporter-2 (SGLT2) inhibitors, and glucagon-like peptide-1 (GLP-1) receptor agonists.2

Type 2 Diabetes Medications That Induce Weight Loss

The following is a list of FDA-approved medications for the management of type 2 diabetes that may also result in weight loss. It is important to note that the amount of weight loss can vary depending on the medication, dose, duration of therapy, and lifestyle changes. Speak with your provider to know additional information.

Drug ClassHow It Works Side Effects
Biguanide
Metformin 
Decreases glucose production by the liver and improves insulin sensitivity4Nausea  Vomiting Diarrhea  Constipation Stomach pain Bloating Altered taste,7,8
SGLT2 Inhibitors   Canagliflozin (Invokana®)   Dapagliflozin (Farxiga®)   Empagliflozin (Jardiance®)Reduces reabsorption of filtered sugar and increases urinary glucose excretion9Increased urination Urinary tract infection (UTI) Female genital infection13
GLP-1 Receptor Agonists   Dulaglutide (Trulicity®)   Exenatide
(Byetta®; BYDUREON BCise®)   Liraglutide (Victoza®)   Semaglutide (Rybelsus®; Ozempic®)   Tirzepatide (Mounjaro®)
Simulates GLP-1 receptors to increase insulin secretion and decrease glucagon secretion14Nausea  Vomiting Diarrhea Acute kidney injury Injection site reactions24

Weight Loss Differences 

Biguanides

In a long-term study, patients who took metformin maintained an average weight loss of 6.2% between 6 and 15 years of treatment. Patients who experienced greater long-term weight loss were those who (1) lost more weight during their first year of treatment, and (2) were older in age.5,6

SGLT2 Inhibitors

Various studies demonstrate long-term weight loss effects among patients taking SGLT2 inhibitors. In an analysis of multiple studies, patients had an average weight loss of between 1.5 kg and 2 kg after 4 years of treatment. These effects increased with increasing doses of these medications. Other studies have revealed average weight loss percentages between 2.2% and 3.3% of patients’ starting weight.5, 10-12

Other studies show improved weight loss among patients combining SGLT2 inhibitors with other drugs, such as metformin or GLP-1 receptor agonists. SGLT2 inhibitors may therefore be the drug of choice for patients also with heart and kidney disease.22,23 However, low blood sugar is more likely to occur when they are used as add-ons rather than used alone.30

GLP-1 Receptor Agonists

Studies report a wide range of weight loss effects associated with GLP-1 receptor agonists, from 1 kg to 15 kg depending on the medication.15-21 Weight loss effects depend on dose and treatment durations.5

Like SLGT2 inhibitors, GLP-1 receptor agonists can be used as add-on therapies for patients with heart and kidney disease, but low blood sugar is more likely to occur. 22, 23, 30   

Frequently Asked Questions

Can I eat anything I want while on these medications?

No, food choices still play a significant role in diabetes management.

Different types of diets for patients with diabetes include Mediterranean, low-fat, low-carb, vegetarian, and vegan diets. Additionally, the Dietary Approaches to Stop Hypertension (DASH) approach could prevent more serious complications such as heart or kidney disease among those who have or are at risk for high blood pressure and high cholesterol.22,23

Diet modifications can also enhance natural GLP-1 and insulin production/sensitivity and prevent escalation of antidiabetic therapies while satisfying nutritional needs.24

Do I still have to exercise while on these medications?

Yes, it is recommended to engage in physical activity regularly, even if on medications that can result in weight loss, to prevent development and progression of heart- and kidney-related complications.

Patients with type 2 diabetes are advised to do 150 minutes per week of moderate to vigorous exercise or 75 minutes per week of high intensity exercise over a course of 3 or more days per week.25 Studies report that physical activity can contribute to increased effectiveness of certain medications, including GLP-1 receptor agonists and metformin.25-27

How can I prevent side effects such as nausea, vomiting, diarrhea, bloating, and constipation?

Metformin can cause an upset stomach on initial treatment so it should be taken with food. Note that these side effects should go away over time, so do not skip doses or stop taking metformin without speaking with your provider.7,8

The initial dose of a GLP-1 receptor agonist or SGLT2 inhibitor is typically low to prevent stomach issues but not high enough to help manage your blood sugar. For this reason, your provider may start you on a higher dose, but you should let them know if the stomach side effects become unmanageable for you.28,29

Can I be on multiple of these medications at the same time?

Yes, GLP-1 receptor agonists and/or SGLT2 inhibitors are preferred over other drug classes as add-on treatments to metformin, especially for patients at risk for heart or kidney disease, according to the American Association of Clinical Endocrinology and American Diabetes Association guidelines.

Before adding these medications, your doctor may consider factors such as heart and kidney disease, potential weight loss, and potential adverse effects.22,23 The use of GLP-1 receptor agonists with metformin may also exacerbate diarrhea.29

Click here for PDF

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Content warning: This article discusses suicide.

For transgender youth in the United States, limited access to gender-affirming care is an ongoing issue stemming from multiple barriers, including lack of family support, a shortage of competent providers, and a surge in legislation banning or restricting gender-affirming care.

Barriers to Gender-Affirming Care

“Many transgender minors are fearful of coming out to their parents or have come out and their parents are not supportive of them,” explained Gloria A. Bachmann, MD, MMS, professor in the Department of Obstetrics, Gynecology, and Reproductive Sciences and medical director of the PROUD Gender Center of New Jersey at the Rutgers Robert Wood Johnson Medical School in New Brunswick. “In this scenario, these individuals are unable to get the gender-affirming medical care that would benefit them because they do not have parental support for their health care.”

Even for transgender minors who have supportive guardians, a range of other obstacles may prevent access to needed care. “Gender-diverse youth face continued stigma and discrimination, even in the healthcare system, and as a result they may not access care for fear of not being accepted and affirmed of who they are,” said Samantha V. Hill, MD, MPH, assistant professor of the Department of Pediatrics at Emory University School of Medicine in Atlanta, Georgia.  

Furthermore, “There is a major shortage of both mental health and medical providers who are trained in providing gender-affirming care, which means families may wait for up to a year to receive care, if they are able to access it at all,” according to Jack L. Turban, MD, MHS, assistant professor in the Division of Child and Adolescent Psychiatry and director of the Gender Psychiatry Program at the University of California, San Francisco.

In recent years, a proliferation of passed and proposed legislative bills have added to the stigma, discrimination, and narrow access to care that gender-diverse individuals — and youth in particular — often experience.1,2

“There has been a dramatic increase in legislation geared at reducing or eliminating gender-affirming medical and surgical interventions in minors, and many states have passed these legislative bills into law,” Dr Hill stated.

As a result, some states have no providers who can offer gender-affirming treatment, Dr Turban said. Such legislation has prevailed despite opposition from all major medical organizations, including the American Medical Association, the American Academy of Pediatrics, and the American Psychiatry Association.2 “In some instances, states have even proposed legislation to limit or ban care for adults,” he noted.3 

In a study published in March 2023 in the Journal of Adolescent Health, Dr Hill and colleagues examined the number of anti-trans bills proposed each year in the US from 2010 to 2019 using data from several sources.4 They found that 189 anti-transgender bills were proposed and 13 were passed during the 10-year period.

“These bills focused on a variety of topics including healthcare, youth athletics, bathroom facilities, identity documents and nondiscrimination, and really emphasize that transgender youth and their subsequent health have become a major focus in this country,” Dr Hill explained.

In 2023, 503 anti-trans bills were proposed and 85 were passed, according to the Trans Legislation Tracker.4 Many of these carried over into 2024, and hundreds of new anti-trans bills have already been proposed as of February 2024.

“That is a dramatic increase, even if we look at 2021 and 2022, when only 125 and 148 bills were proposed, respectively,” Dr Hill said.

Negative Impact of Anti-Trans Legislation

In their study, Dr Hill and her team “found that this change in the legislative climate not only impacted self-reported feelings of being victimized and bullied by gender-diverse youth, but it also impacted non-gender-diverse youth,” she noted.4

In their statement to Endocrinology Advisor, the Endocrine Society said that such legislation is based on widespread misinformation and stated, “We recognize the risks of blocking adolescents from accessing gender-affirming care: It raises the risk of suicidal ideation and self-harm and denies patients the benefits of treatment, including improved psychological functioning.”6

As an example, the Endocrine Society pointed to a 2020 study by Dr Turban et al, which showed lower odds of lifetime suicidal ideation among transgender adults who received puberty-delaying medication during adolescence compared with those who did not receive such treatment, even after adjustment for demographic variables and family support (adjusted odds ratio, 0.3; 95% CI, 0.2-0.6). Approximately 9 out of 10 participants who wanted but did not receive pubertal suppression reported lifetime suicidal ideation.7

https://infogram.com/endo_feature_315-1h0n25o8n7q8l4p?live

Among other recent research in this area, a prospective cohort study of 104 transgender and nonbinary youths found that receipt of gender-affirming care (in this case, puberty blockers and gender-affirming hormones) was linked to 60% lower odds of depression and 73% lower odds of suicidality during the subsequent 12 months.6 A large, survey-based study published in 2022 in the Journal of Adolescent Health reported similar results.8

The Endocrine Society added that banning care for adolescents creates the need for additional gender-affirming procedures in adulthood.

“Blocking pubertal hormones early in puberty prevents a teenager from developing irreversible secondary sex characteristics, such as facial hair and breast growth,” it explained. “Transgender and gender-diverse individuals who did not have access to care as teenagers may need additional treatment to address hair growth, voice changes, and facial development.”

The Endocrine Society also cited research showing that state restrictions on gender-affirming care have increased median drive times to medical appointments for youth seeking such care, with the largest absolute increases observed in Florida (8.5 hours), Texas (6.7 hours), and Utah (5.0 hours).  According to the study authors, increased travel times and associated costs may further impede treatment access and negatively affect mental health among transgender youths.1  

"
Transgender and gender-diverse teenagers, their parents, and physicians should be able to determine the appropriate course of treatment, and banning evidence-based medical care based on misinformation takes away the ability of parents and patients to make informed decisions.

“Bans and restrictions on gender-affirming care contradict mainstream medical practice and scientific evidence, and these policies are taking medical decision-making out of the hands of transgender and gender-diverse teenagers, their families, and their physicians,” the Endocrine Society told Endocrinology Advisor. “Cisgender teenagers, together with their parents or guardians, are currently deemed competent to give consent to various medical treatments, and transgender teenagers should be afforded the same legal rights.”9,10

Dr Bachman emphasized that gender-affirming care for minors is provided by a healthcare team that thoroughly evaluates each patient, and many studies have shown high rates of patient satisfaction with such care: “The largest of these studies was the 2022 US Trans Survey that included 92,329 respondents, in which 98% who were given hormones for their gender identity or transition were either a lot more satisfied or a little more satisfied.”11

Increasing Competency in Gender-Affirming Care

The experts interviewed for this article recommend various strategies for increasing clinical competency in gender-affirming care and advocating for gender-diverse individuals at large.

“There are 2 major sets of guidelines for providing gender-affirming medical care — the Endocrine Society Guidelines and the World Professional Association for Transgender Health Standards of Care — that physicians should use to inform their practice,” Dr Turban said.12,13 

The Endocrine Society guideline, which cites more than 260 research studies, states that adolescents are eligible for hormone therapy when they are mentally competent to fully understand and consent to this partially irreversible treatment, which is typically around the age of 16 years.12 

The Endocrine Society has also published a position statement on transgender health and the importance of access to gender-affirming care, as well as a toolkit for clinicians who want to advocate for transgender health care in their home states.14,15 In addition, providers can check the Kaiser Family Foundation’s policy tracker to follow emerging developments in restrictive legislation regarding gender-affirming care.16

“Sadly, the media landscape in this area has been saturated with non-experts and political propaganda that is not evidence-based, so it’s essential that the voices of physicians be heard both in the media and in legislative debates,” Dr Turban stated. “I encourage physicians to write evidence-based op-eds in their local or state papers when legislation arises and to reach out to their local representatives to educate them on the science relevant to bills that would impact the care of transgender patients.”17

In terms of treatment, “For those clinicians who do not have the clinical background to provide gender-affirming care, referral to medical establishments that do, such as the PROUD Gender Center of New Jersey, is extremely important,” Dr Bachman advised.

Dr Hill said more work is needed to educate all health care workers about gender-affirming care and how to link gender-diverse youth to these services. “There is a lack of a road map for gender-diverse youth and those who support them, and many families are unaware of how to access care from providers knowledgeable in gender-affirming care.”

She provided the following recommendations for clinicians interested in providing gender-affirming care in their practices:

  • A great place to start is with creating a welcoming environment for gender-diverse youth in clinical settings, as recommended by many professional organizations including the American Academy of Pediatrics.18 This includes documenting asserted names and pronouns in the electronic medical record, use of gender-neutral language, and educating staff in affirming all patients.
  • It is important for clinicians to educate themselves about appropriate ways to affirm someone's gender and to understand gender expression and gender identity. There are many resources for clinicians to access, such as those provided by Fenway Health. They can also follow the vast literature on the subject that is evidence-based.
  • In general, clinicians can advocate for gender-diverse youth by correcting people who have misconceptions about these individuals or who misgender them by using the wrong pronouns.
  • Clinicians can be agents of change wherever they are providing care and introducing the topic if gender-affirming policies are not already in place.
  • Clinicians can sign up to receive updates as legislation is proposed within local, state, and national jurisdictions so they can be informed about how the law changes and help disseminate accurate information to their colleagues and the communities they serve.
  • Engaging in advocacy days at the state or national capitol and sharing scientifically accurate information about gender-diverse youth and their families are other great ways to advocate.
  • For more ideas, clinicians can visit the National Institute for Children’s Health Quality website.19 

“Transgender and gender-diverse teenagers, their parents, and physicians should be able to determine the appropriate course of treatment, and banning evidence-based medical care based on misinformation takes away the ability of parents and patients to make informed decisions,” according to the Endocrine Society. “Medical evidence, not politics, should inform treatment decisions.”

Further Reading

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Author’s Note: This periodic feature will focus on legal issues faced by endocrinologists and other health care practitioners. It will use case studies to illustrate topics such as the elements of medical malpractice, HIPAA, informed consent, delayed diagnosis, and other issues. We hope you will find it informative and useful in your practice.

What requirements must a medical malpractice case meet in order to survive a motion to dismiss? Under what circumstances can one claim be dismissed, but another be allowed to proceed to a jury? These are the questions that arose after an endocrinologist was sued by a former patient for medical malpractice and lack of informed consent. The physician tried to have the claims against him dismissed, but he was only partially successful. Let’s look at the reasons why.

Facts of the Case

Dr E was an endocrinologist working in a busy and varied practice. One of his patients was Mr P, aged 66 years. Mr P had been referred by his primary care physician for testosterone deficiency.

“I just don’t have the energy that I used to,” Mr P reported. “Not in the bedroom either. My regular doctor suggested that you might be able to help.”

Dr E went over the blood test results with the patient, showing him low testosterone levels and explaining how hormone replacement therapy worked. Mr P was enthusiastic about starting on the testosterone replacement.

The therapy seemed to help the patient and he continued using it under the physician’s supervision for the next couple of years. When Mr P was aged 69 years, however, he was diagnosed with prostate cancer and blamed Dr E for the condition.

“The doctor never warned me that testosterone replacement could give me prostate cancer,” the patient told the personal injury attorney he had hired to represent him. “If I had been told that, I would never have agreed to use it!”

The attorney filed the paperwork, and Dr E was informed that he was being sued for medical malpractice and lack of informed consent. Specifically, the plaintiff alleged that Dr E (1) was negligent in prescribing testosterone replacement therapy to the patient and (2) failed to inform the patient of the risks, hazards, and alternatives to the therapy, which prevented the patient from giving informed consent.

In order to support his case, the patient introduced testimony from a medical expert, as well as deposition testimony from the patient himself, in which he testified that Dr E never warned him that prostate cancer could result from testosterone replacement therapy.

Dr E met with the defense attorney provided by his medical malpractice insurance. Although Dr E told the attorney that he typically went over the pros and cons of testosterone replacement therapy and potential alternatives, he had no written documentation that he had actually done so in this case.

The defense attorney made a motion for summary judgment, asking for the dismissal of the two claims against Dr E.

The Medical Malpractice Claim

To survive a summary judgment motion, the plaintiff needed to show that there was a triable issue of fact, which would normally be done via expert medical testimony. However, the plaintiff made a poor choice of expert.

To support his case, the plaintiff introduced the affidavit of a medical expert. However, the expert was not an expert in the field of endocrinology nor hormone replacement therapy. The expert was actually trained in pathology and had no specific training nor expertise in endocrinology.

“Moreover,” the court in its decision, “he did not indicate that he had familiarized himself with the relevant literature or otherwise set forth how he was, or became, familiar with the applicable standards of care in this specialized area of practice.”

"
Had Dr E taken a few moments to document his conversation with the patient in the patient records, the issue of whether the patient had been properly informed might never have come up.

The court went on to state that “while it is true that a medical expert need not be a specialist in a particular field in order to testify regarding accepted practices in that field...the witness nonetheless should be possessed of the requisite skill, training, education, knowledge or experience from which it can be assumed that the opinion rendered is reliable.”

By contrast, the defendant introduced the affidavit of an expert endocrinologist who testified that Dr E’s treatment of the plaintiff’s low testosterone through hormone replacement therapy was performed in accordance with good and accepted standards of medical practice.

The court held that since the plaintiff’s expert “failed to lay the requisite foundation for his asserted familiarity with endocrinology and testosterone replacement therapy, his affidavit was of no probative value.”

Without the proper foundation, a legal claim will fail. The court, thus, dismissed the medical malpractice charge against Dr E.

The court, however, declined to dismiss the informed consent claim against Dr E because there was a factual dispute about what happened. The plaintiff testified that the doctor had never explained the risks to him and that he would not have agreed to the treatment had he known the risks. The doctor believed he had discussed the issues but had no proof that he had, in fact, warned the patient.

To establish a cause of action for malpractice based on lack of informed consent, a plaintiff must prove that (1) the clinician failed to disclose risks and alternatives to treatment that a reasonable medical practitioner would have disclosed and (2) a reasonably prudent patient in the same position would not have undergone the treatment if he was fully informed.

Because of the legitimate factual dispute as to whether Dr E informed the patient of potential risks, the court held that this issue must go to a jury to decide and allowed this prong of the case to proceed against the physician.

Protecting Yourself

Dr E assumed that he had gone over the risks and benefits of the treatment with the patient because that was what he believed he typically did. Yet without a record that he did so, it is just one person’s word or memories vs another’s.

Had Dr E taken a few moments to document his conversation with the patient in the patient records, the issue of whether the patient had been properly informed might never have come up. A moment of documentation can save a great deal of time and money in legal costs.

Disclosure: Cases presented are based on actual occurrences. Names of participants and details have been changed. Cases are informational only; no specific legal advice is intended. Persons pictured are not the actual individuals mentioned in the article.

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Our easy-to-read fact sheets provide clinicians with reliable information to share with patients and their caregivers.

Diabetes is a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces. Insulin is a hormone that regulates blood-sugar levels. There are various classifications and pathophysiologies of diabetes.

Metformin1

Metformin is an antidiabetic medication that falls under a drug class called biguanides. Metformin is FDA approved to be used together with diet and exercise to improve blood-sugar control among adults and children aged 10 years or older with type 2 diabetes.

Metformin decreases how much glucose the liver produces, decreases how much glucose the intestines absorb, and increases insulin sensitivity. Increasing insulin sensitivity allows the body to better use the insulin it’s already producing. Metformin does not affect how much insulin the body is producing.

Metformin can be a good treatment option for patients with different types of diabetes, as indicated below.

Prediabetes

Prediabetes occurs when an individual’s blood-sugar levels are higher than normal but not high enough to be classified as diabetes. Those with prediabetes have a higher chance of developing type 2 diabetes.2 For some individuals, this is a reversible condition through lifestyle modifications and medications.3

Metformin’s place in therapy: Metformin can be used in individuals with prediabetes at high risk for type 2 diabetes, but lifestyle modifications have been shown to decrease the risk more than the use of metformin. Metformin shows greater benefit for individuals with a higher body mass index (BMI) who have prediabetes.2

Type 1 Diabetes4

Type 1 diabetes is also known as insulin-dependent diabetes or juvenile-onset diabetes. Approximately 5 to 10% of patients with diabetes fall under this category. Type 1 diabetes is an autoimmune disorder that causes the body to gradually stop making insulin, leading to high blood-sugar levels. 

Metformin’s place in therapy: There is limited evidence of the efficacy of metformin among patients with type 1 diabetes, but there may be benefit among patients aged older than 65 years and those who are overweight or obese.5-7

Type 2 Diabetes4

Type 2 diabetes is also known as non-insulin-dependent diabetes or adult-onset diabetes. Approximately 90 to 95% of patients with diabetes fall under this category. This occurs when your body produces insulin but is unable to use it well. 

Type 2 diabetes progresses slowly. It is often underdiagnosed until symptoms — including weight loss, growth impairment, blurry vision, frequent urination, and extreme thirst — begin to appear, indicating severely high blood-sugar levels.

Lifestyle modifications are important for the management of diabetes and to prevent long-term organ damage, particularly in the eyes, kidney, heart, and nerves.

Metformin’s place in therapy: Metformin is the first line of therapy for patients with type 2 diabetes or at high risk of type 2 diabetes.6

Gestational Diabetes4

During pregnancy (and more commonly during the second or third trimester), patients could develop glucose intolerance that usually resolves after childbirth or towards the end of the pregnancy. Approximately 1 to 14% of patients who are pregnant may experience gestational diabetes.

Weight loss for individuals more than 20% over their ideal body weight, exercise, and maintaining a healthy diet may lower the risk of developing type 2 diabetes.5

Metformin’s place in therapy: Metformin is not recommended as first-line medications for individuals who are pregnant because it crosses the placenta. Individuals with a history of gestational diabetes who later have prediabetes are recommended to undertake lifestyle modifications with or without metformin to prevent diabetes.6

Frequently Asked Patient Questions

Are there any side effects associated with metformin use?

Metformin is generally considered safe and well-tolerated. Common side effects include diarrhea, nausea, vomiting, flatulence, indigestion, abdominal discomfort, and headaches.1 If you experience these symptoms, speak with your doctor — starting at a lower dose and slowly increasing the dose may help with some of these side effects.

Long-term use of metformin may be associated with vitamin B12 deficiency. Your doctor should be measuring your vitamin B12 level periodically.6

Are there any drug interactions with metformin?

Metformin could significantly interact with alcohol; topiramate, zonisamide, acetazolamide, and dichlorphenamide; insulin; oral contraceptives; and certain blood pressure medications. Share your medication history with your doctor before taking metformin.1 

Who shouldn’t take metformin?

Individuals who are pregnant, are anticipating to become pregnant, have kidney insufficiency, or have impaired liver function should not take metformin.1,6 Consult with your doctor before beginning metformin if you have any of these conditions.

When should I stop taking metformin?

If you’re experiencing symptoms of lactic acidosis, discontinue metformin immediately and contact your doctor. Lactic acidosis can present as malaise, respiratory distress, abdominal pain, drowsiness or a strong desire to fall asleep, or muscle pain.

If you’re successfully managing your diabetes with lifestyle changes, your doctor may suggest you stop taking metformin. This may happen if your hemoglobin A1c level is less than 6.5% for at least 6 months.1

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