Finding the Right Metformin Titration Regimen
Developing a stepwise metformin regimen begins with doing your homework.
Janet Brown-Friday, RN, MSN, MPH, and Clinical Trials Manager at the Albert Einstein College of Medicine's Diabetes Clinical Trials Unit (DCTU), discusses how to work with your patient to develop the most effective metformin regimen.
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There's a combination of things that we would do to help somebody who has difficulty with taking metformin. When you first initiate the dosing of metformin, you would start at a lower dose. Of course, sometimes people have very high blood sugars and you want to address that immediately—but you don't want to bombard somebody or blast them with a high dose of a medication like metformin, because more than likely they're going to have some type of gastric effect. There are some people who have no problem whatsoever, but we can't predict that in advance, so you start with a low dose and slowly increase the dose. The other thing that we would do or explain to the patient is that it's very important that they take the medication with food—and try not to take it on an empty stomach.
Some of the challenges that I have experienced with people who take metformin are mostly of the gastrointestinal (GI) aspect, meaning they have issues with stomach pain, some have nausea, some have bloating, some have diarrhea, some even have some vomiting with metformin.
Commonly the starting dose might be about 500 mg of metformin, and then we can increase the dose or titrate the dose up over time—like about a week at a time—to increase it to a higher dose. So you might go from 500 mg for a week, and then go to 1,000 mg for a week, and then depending on what's happening with the person's blood sugar…depending on where their blood sugar started out, you might stop with 1,000 mg, or you might increase it again to 1,500 mg. And usually the maximal dose of metformin is 2,000 mg daily, which, in many cases, will be taken two times per day.
The other thing that you have to consider is that there is not just one form of metformin. Metformin has multiple forms. The two major forms are either immediate release or extended release. The extended release was designed so that it's encapsulated and it slowly releases into the system, and people have found that they have less GI or gastric side effects with the extended release.
In relation to taking metformin and trying to be successful with your patient taking the medication, rather than just focusing on prescribing a medication, focus on your patient. First, know your patient. What is the personality of that person? Is this somebody who's going to listen to what you have to say, do you think? Because you know your patient as best you can. Build a trust with that patient. If you stop to listen to the concerns of that person, the person, I think, is going to trust you and be more willing to be adherent to their medication. Also, when you start a new medication with somebody, if your patient knows the side effects, knows what to expect when they're taking a medication and they have one of those side effects, it's like, "Okay, I was told that would happen and so therefore I understand that I should continue to take it until that time." And also, open the doors so that they know they can contact you.
If you are concerned about the use of metformin, then you should learn more about it. Watching a blog or listening to one person's feeling about it is not necessarily going to do the job. Do your homework and see what your colleagues have said about it, what they say about it in the professional journals, because there's a lot of information, and so many research studies that have used metformin, both here in the United States and in Europe.
About Janet Brown-Friday, RN, MSN, MPH
Janet Brown-Friday, RN, MSN, MPH has been a registered nurse for 34 years and is currently the Clinical Trials Manager of the Albert Einstein College of Medicine's Diabetes Clinical Trials Unit (DCTU). At Einstein she manages the clinical and administrative operations of both National Institutes of Health and locally funded clinical trials.