Is metformin an appropriate first-line monotherapy for a patient with an A1c of 7.2%?

• A. Yes, metformin can be used as monotherapy
• B. No; insulin should be started
• C. Only if lifestyle modifications fail to improve glycemia
• D. Only in combination with sulfonylurea

Answer: (A)

Metformin is the preferred first-line pharmacologic therapy for many adults with type 2 diabetes who have no contraindications. It works by reducing hepatic glucose production and improving insulin sensitivity, and it generally lowers the A1c by about 1–1.5%. With an A1c of 7.2%, starting metformin as monotherapy is appropriate because this level indicates mild-to-moderate hyperglycemia where an oral agent with low hypoglycemia risk and potential weight neutrality is suitable. Insulin is not required at this stage unless there are specific indications such as very high A1c, symptomatic hyperglycemia, or catabolic states. Initiating metformin does not depend on lifestyle changes failing first; lifestyle modification can be implemented alongside metformin. Adding a sulfonylurea or starting combination therapy isn't necessary here unless A1c remains above target after a trial of metformin.