Based on the medical community’s extensive experience and the drug’s demonstrated efficacy, safety and low-cost, metformin should remain the “foundation therapy” for all patients with type 2 diabetes, barring contraindications.

Metformin is contraindicated in:

• Patients with severe renal dysfunction (GFR <30 mL/min/1.73 m²).
• Hypersensitivity to metformin and metabolic acidosis.
• Metformin dosing should also stop on the day of any surgery.
• Discontinue metformin before giving iodinated contrast agents in patients with a GFR <60 mL/min/1.73 m², lactic acidosis risk factors.
• Metformin may be restarted after the procedure once the patient’s GFR has normalized.
• Avoid metformin in hepatically impaired or unstable heart failure patients.

SGLT2 inhibitors or GLP-1RA may only be considered as first-line therapy in case of ASCVD or high/very high CV risk.