Why Doctors Still Prescribe Metformin: Dispelling the Myth of Discontinuation

October 6, 2025 •

4 min read

Despite a common misconception, prescription rates for metformin in the U.S. have more than doubled from 2004 to 2022, confirming that doctors still widely prescribe this first-line medication. The idea that physicians no longer prescribe metformin likely stems from a combination of the 2020 FDA recalls and the rise of popular newer alternatives, but it remains a staple in diabetes management for most patients.

Quick Summary

This article clarifies why metformin remains a standard treatment for type 2 diabetes, addressing misconceptions from recalls. It details its benefits, common side effects, and how it compares to newer medications in modern, personalized care.

Key Points

Metformin remains first-line: It is still the recommended starting medication for most patients with type 2 diabetes due to its proven efficacy, safety, and low cost.
The 2020 recall was limited: The FDA recall only affected specific extended-release batches from certain manufacturers due to NDMA impurities, not the entire drug class.
Newer drugs offer targeted benefits: Medications like GLP-1 agonists and SGLT-2 inhibitors provide additional cardiovascular and weight-loss benefits and are often used alongside or instead of metformin for high-risk patients.
Reasons for alternatives exist: Doctors may prescribe alternatives due to patient intolerance to metformin's side effects, contraindications like kidney disease, or to pursue additional health outcomes like weight loss.
Treatment is more personalized: Modern diabetes care involves tailoring medication choice based on a patient's overall health profile, moving beyond a single standard approach.
Prescription rates remain high: Despite rumors, metformin prescription rates have increased over time, indicating its continued widespread use.

Metformin's enduring role as first-line therapy

For over six decades, metformin has served as the cornerstone of medical management for type 2 diabetes mellitus (T2DM). Its continued prominence is no accident; the medication boasts a robust track record of efficacy, safety, and affordability that few other drugs can match. Metformin primarily works by decreasing glucose production in the liver and improving the body's response to insulin, without causing weight gain or significant risk of low blood sugar (hypoglycemia) when used alone.

International and national guidelines, including those from the American Diabetes Association (ADA), continue to recommend metformin as the preferred initial pharmacologic treatment for T2DM, unless the patient has a specific contraindication or cannot tolerate the drug. Its proven effectiveness in lowering HbA1c levels, coupled with its relatively low cost, makes it an accessible and reliable option for a vast number of patients worldwide. Furthermore, studies have indicated potential cardiovascular benefits associated with metformin, adding another layer to its appeal as a foundational therapy.

Addressing the concerns: Understanding the 2020 recalls

The most significant factor fueling the misconception that doctors no longer prescribe metformin was the 2020 FDA recall of certain batches of extended-release (ER) metformin. The recall was prompted by the detection of trace amounts of N-nitrosodimethylamine (NDMA), a potential carcinogen, in some products.

It is crucial to understand the specifics of this event:

Targeted Recall: The recall was not for all metformin products but specifically for certain batches and manufacturers of the extended-release formulation.
Precautionary Measure: The levels of NDMA found were slightly above the acceptable daily intake limits and did not pose an immediate health threat, but the recall was a precautionary safety measure.
No Ban: The FDA did not ban metformin. The majority of the drug on the market, including the immediate-release formulation, was unaffected and continued to be prescribed. The recall led to temporary shortages but did not end the drug's use.

This event caused understandable concern among patients and the public, creating the impression that the drug was unsafe. However, doctors continued to prescribe unaffected metformin products, and the drug remains a trusted treatment option.

Newer medications and personalized care

The landscape of diabetes treatment has evolved significantly, with newer classes of drugs offering specific advantages, especially for patients with comorbidities. This expansion of choice, not the failure of metformin, is what has truly changed the prescribing patterns. Newer medications, like GLP-1 receptor agonists and SGLT-2 inhibitors, are not typically seen as direct replacements for metformin but rather as potential additions or alternatives depending on the patient's overall health profile and goals.

These newer options offer important benefits, particularly related to cardiovascular health and weight management, which have shifted treatment guidelines toward a more personalized approach. For instance, a patient with pre-existing heart disease might be started on a SGLT-2 inhibitor or GLP-1 RA in addition to or even instead of metformin to maximize cardiovascular protection. This shift towards outcome-focused care, rather than solely glycemic control, means doctors have more tools at their disposal to tailor treatment plans.

Comparison of Metformin with Newer Drug Classes


Feature	Metformin	GLP-1 Receptor Agonists (e.g., Ozempic)	SGLT-2 Inhibitors (e.g., Jardiance)
Mechanism	Reduces liver glucose production; improves insulin sensitivity.	Mimics hormone to increase insulin, suppress glucagon, slow gastric emptying.	Blocks glucose reabsorption in kidneys, increasing its excretion in urine.
Administration	Oral pill (immediate or extended-release).	Once-weekly or daily injection; oral version exists.	Oral pill, usually daily.
Cost	Highly affordable generic.	Significantly more expensive.	Significantly more expensive.
Weight Impact	Weight-neutral or modest weight loss.	Significant weight loss.	Modest weight loss.
Cardiovascular Benefit	Proven benefits, particularly in preventing cardiovascular death in some studies.	Strong evidence for reducing major cardiovascular events.	Strong evidence for reducing major cardiovascular events and heart failure risk.
Common Side Effects	Gastrointestinal issues (diarrhea, nausea, gas).	Gastrointestinal issues (nausea, vomiting, diarrhea).	Genital mycotic infections, urinary tract infections.

When and why a doctor might use an alternative

While metformin remains the starting point for many, it is not suitable for everyone. Certain contraindications and potential side effects can prompt a doctor to choose a different medication from the outset or to add a second or third agent.

Reasons for using a metformin alternative include:

Intolerance to side effects: A significant minority of patients experience persistent gastrointestinal side effects like diarrhea and nausea, even with the extended-release formula.
Kidney or liver disease: Metformin is contraindicated in patients with advanced kidney or liver failure due to an increased risk of lactic acidosis, a rare but serious side effect. Newer guidelines allow for use in moderate kidney disease but still require caution and monitoring.
Desired additional benefits: A patient who needs significant weight loss or has a high risk of cardiovascular events might be better served by a GLP-1 RA or SGLT-2 inhibitor, either in combination with or instead of metformin.
Vitamin B12 deficiency: Long-term use of metformin can interfere with vitamin B12 absorption, leading to a deficiency that requires monitoring and supplementation.

Conclusion: Metformin is here to stay

The assertion that doctors no longer prescribe metformin is a significant misunderstanding. The drug remains the most widely prescribed oral diabetes medication globally, a testament to its effectiveness, safety profile, and affordability. The confusion stems from specific, temporary recalls and the expansion of the diabetes treatment toolkit, which now includes potent newer drug classes. Doctors are not abandoning metformin; they are simply practicing more personalized medicine, considering each patient's unique needs, comorbidities, and desired outcomes. For most patients with type 2 diabetes, metformin is still the most logical and effective first step in their treatment journey.

Authoritative Link

For more information on the FDA's statement regarding the 2020 metformin recall, consult the American Diabetes Association® newsroom.

Frequently Asked Questions

No, this is a myth. The widespread use of metformin continues. A specific recall occurred in 2020 for certain batches of the extended-release formulation, not the entire drug. Most immediate-release metformin products and many ER products were unaffected.

The misconception likely stems from the specific FDA recalls in 2020, which created significant public concern, and the increasing use of newer, heavily marketed diabetes medications that some mistake for replacements rather than additions.

A doctor might choose an alternative if a patient cannot tolerate metformin's gastrointestinal side effects, has advanced kidney or liver disease, or if additional benefits like significant weight loss or cardiovascular protection are prioritized.

Newer drugs, such as GLP-1 receptor agonists and SGLT-2 inhibitors, often have different mechanisms and offer specific advantages like cardiovascular benefits and weight loss. However, they are typically more expensive and can have different side effects.

The most common side effects are gastrointestinal, including diarrhea, nausea, stomach discomfort, and gas. These often subside over time, especially with the extended-release formula, and can be minimized by taking the medication with food.

Yes, metformin is sometimes prescribed off-label for conditions like polycystic ovary syndrome (PCOS) and gestational diabetes. It may also help manage symptoms of prediabetes.

No, the recall was a precautionary measure for specific batches with NDMA impurities. The overall safety profile of metformin is well-established, and it has been used safely for decades.