Metformin prescribing trends
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Global Trends in Metformin Prescribing
Metformin prescribing has increased significantly worldwide over the past two decades. In the United States, metformin prescriptions rose steadily from 2000 to 2015, with both FDA-approved and off-label uses expanding. The most substantial increases were seen in adults aged 50 and older, and off-label use also grew, particularly for endocrine, cardiovascular, and reproductive disorders . Similar upward trends were observed in Korea, where metformin use among adults with type 2 diabetes increased from 52.9% of antidiabetic prescriptions in 2002 to 80.4% in 2013, making it the most commonly used antidiabetic drug . In Australia, national data showed a fivefold increase in metformin utilization between 1995 and 2012 Moon2016Moon2016. In Europe, specifically in Tyrol, Austria, metformin remained the most frequently prescribed antidiabetic drug from 2012 to 2018 . Recent data from Bosnia and Herzegovina also confirm metformin as the most prescribed oral antihyperglycemic drug in 2022 and 2023 .
Metformin Prescribing Patterns and Combinations
Metformin is not only widely used as monotherapy but also as part of combination regimens. In England, metformin-based single pill combinations saw an average annual increase in prescriptions and costs between 2015 and 2020, with metformin–DPP-4 inhibitor combinations being the most popular . In Korea, dual and triple drug combinations involving metformin have become more common, with metformin and sulfonylureas or DPP-4 inhibitors being the most frequently prescribed combinations . In India, metformin was included in 95% of diabetes prescriptions, often in combination with sulfonylureas or DPP-4 inhibitors .
Metformin Use in Chronic Kidney Disease (CKD)
Metformin prescribing in patients with CKD has evolved, especially after regulatory changes. In the US, following the 2016 FDA label update allowing metformin initiation at higher levels of kidney function, new prescriptions increased, particularly in patients with moderate CKD (stages 3a and 3b) . In Korea, metformin remained the most prescribed antidiabetic drug in CKD patients, except in those with end-stage renal disease, where its use declined in favor of insulin and other agents. The risk of metformin-associated lactic acidosis was low, but use decreased significantly in advanced CKD stages . In Australia, metformin was often prescribed even in patients with renal impairment, sometimes at higher-than-recommended doses, despite prescribers’ awareness of the need for dose adjustment Moon2016Moon2016.
Shifts in Antidiabetic Drug Preferences
Across multiple regions, the rise in metformin use has been accompanied by a decline in sulfonylurea prescriptions and an increase in newer agents like DPP-4 inhibitors and SGLT2 inhibitors Ko2016Engler2020Joo2024. These shifts reflect changing clinical guidelines and emerging evidence from cardiovascular outcome trials, which have influenced prescribing practices even before formal guideline updates .
Cost and Adverse Events
While the overall cost of antidiabetic medications has increased, the proportion of costs attributed to metformin has decreased in some regions, such as England, due to the introduction of more expensive combination therapies and newer agents . Metformin continues to have a favorable safety profile, with the lowest rate of adverse drug reactions among oral hypoglycemic agents .
Conclusion
Metformin prescribing has grown substantially worldwide, driven by its effectiveness, safety, and expanding indications. It remains the cornerstone of type 2 diabetes management, both as monotherapy and in combination regimens. Prescribing patterns are adapting to new evidence and regulatory changes, especially in populations with CKD. Despite rising costs and pill burdens, metformin’s widespread use underscores its central role in diabetes care, while ongoing monitoring and optimization of therapy remain important as new agents emerge.
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