Type 2 diabetes mellitus affects hundreds of thousands of Romanians, and the cornerstone of oral treatment has remained, for over six decades, metformin. Before being a mere "blood sugar medicine," metformin is the molecule with the best efficacy-cost-safety ratio in diabetology. Here is how oral antidiabetics work, what doses are usual and what the real side effects are — for information, not as a substitute for the doctor.
Metformin: first line and why
Metformin (a biguanide) does not "squeeze" the pancreas. It acts mainly by reducing hepatic glucose production (gluconeogenesis) and by increasing tissue sensitivity to insulin. Two practical consequences: as monotherapy it does not cause hypoglycemia and does not increase weight — sometimes it even lowers it slightly. That is why the EMA guidelines and the ADA/EASD ones recommend it as the first option for most patients with type 2 diabetes, alongside lifestyle modification.
The brands available on the Romanian market include Siofor, Glucophage and numerous metformin generics; there are also XR forms (extended release), better tolerated digestively. Almost all are reimbursed through CNAS, with prescription by the family doctor or diabetologist.
Usual doses and slow titration
The golden rule is "start low, go slow": it usually begins with 500 mg once a day, with a meal, and is increased gradually (typically up to 850–1000 mg twice a day), precisely to reduce the digestive effects. The usual maximum dose is around 2000–3000 mg/day, depending on tolerance and renal function. Taking it during the meal and the XR form help the sensitive stomach.
Real side effects
The most frequent: digestive disturbances (nausea, diarrhea, cramps) — usually at the beginning and reversible with slow titration. In the long term, metformin can lower the level of vitamin B12, which is why a periodic measurement is reasonable for chronic users. Lactic acidosis is very rare, but serious; that is why metformin is avoided in advanced renal failure (glomerular filtration rate below 30) and is temporarily stopped before investigations with iodinated contrast medium.
The other oral classes, in brief
When metformin is not sufficient, the following are added (not automatically replaced): sulfonylureas (gliclazide, glimepiride) stimulate insulin secretion — effective, but with a risk of hypoglycemia and weight gain; SGLT2 inhibitors (dapagliflozin, empagliflozin) eliminate glucose through urine and have demonstrated cardiovascular and renal benefits; DPP-4 inhibitors (sitagliptin) are weight-neutral and well tolerated; GLP-1 receptor agonists (semaglutide) add significant weight loss. The choice depends on the cardiovascular, renal and weight profile of each patient — a specialist decision.
What is up to you
No tablet replaces diet, exercise and blood sugar monitoring. Do not change the doses on your own, do not skip check-ups and tell your doctor if persistent digestive effects appear. To compare the updated prices of metformin and the other antidiabetics in nearby pharmacies, use the search on HartaFarmacii.
- ANMDMR — Summaries of product characteristics for metformin and analogues
- EMA — information on antidiabetic medicines
- ADA/EASD guidelines — management of hyperglycemia in type 2 diabetes
- CNAS / CANAMED — reimbursement lists