Initial Therapy
Most patients should begin with lifestyle changes (lifestyle counseling, weight-loss education, exercise, etc.). When lifestyle efforts alone have not achieved or maintained glycemic goals, metformin monotherapy should be added at, or soon after, diagnosis, unless there are contraindications or intolerance. Metformin has a long-standing evidence base for efficacy and safety, is inexpensive, and may reduce risk of cardiovascular events (16). In patients with metformin intolerance or contraindications, consider an initial drug from other classes depicted in Fig. 7.1 under “Dual therapy” and proceed accordingly.