For Mr C with newly diagnosed type 2 diabetes and a BMI of 29.9 kg/m2, which therapy is most appropriate to initiate?

• A. Metformin
• B. Insulin
• C. Sulphonylurea
• D. GLP-1 receptor agonist

Answer: (A)

Metformin is the first-line choice for adults with newly diagnosed type 2 diabetes, especially when overweight or near the overweight range is present. It improves insulin sensitivity and reduces hepatic glucose production, leading to good glycemic control with a low risk of hypoglycemia when used alone. Metformin is also associated with weight neutrality or modest weight loss, which is particularly advantageous for someone with a BMI around 29.9. It has a favorable safety profile, but kidney function should be checked before starting and monitored over time, since higher risk of lactic acidosis exists with significant renal impairment.

Insulin is typically reserved for patients with very high blood glucose or symptomatic hyperglycemia, or after failure of oral therapy; it carries a higher risk of hypoglycemia and requires injections. Sulphonylureas can lower glucose but often cause weight gain and hypoglycemia. GLP-1 receptor agonists can promote weight loss but are injections and more costly, and are usually considered after metformin or in specific situations.