What should I consider when deciding between metformin and Trulicity?
September 14, 2021 12:16 PM   Subscribe

My doctor has given me two options to help lower my A1C, and I'm wondering what experience people have had with metformin and Trulicity. I'm currently using metformin, and my doctor said I should either increase my dose or switch to Trulicity, and I'm curious how other people may have made a decision about these options.

My previous A1C was 11.2, and I had a goal to also lose some weight. My doctor started me on 500mg of metformin twice a day. After using the metformin for two months, eating better, and exercising, I have lost about ten pounds and my A1C is down to 8.0.

Now, my doctor is recommending that I start a weekly injection with Trulicity, or as a Plan B, increasing the metformin to 1,000mg twice a day.

My doctor was pushing the Trulicity hard, but I feel like what I'm doing is working, and that continuing with eating healthier, exercise, and the metformin will help me reach my goals.

Has anyone faced a high A1C and considered these options? Did you use metformin or Trulicity, and what were the factors that helped you make this decision?

[Because of coronavirus restrictions, it could be a while before I can get in to see a different doctor to get a second opinion. Hearing how other people dealing with a high A1C thought through their options and made a decision would be helpful for me.
posted by davidstandaford to Health & Fitness (10 answers total) 4 users marked this as a favorite
not specifically about these meds, but when faced with similar issues i have increased the dosage of the med i am currently on that is working. i know it works. i either didn't have side effects or they went away or i can deal with them. if the increased dosage of the known med makes me sick, or doesn't have the desired results, then i try the next (usually more expensive) option.
posted by misanthropicsarah at 12:30 PM on September 14 [1 favorite]

I’m on that higher dose of Metformin. I’m doing well on it and don’t have any plans to switch*. But I discussed it with my diabetes educator and she swears by the injectable like Trulicity. Excellent control of blood sugar and no progression of the disease over a 15 year period in research studies. Which is apparently remarkable.
*mainly because of insurance issues.
posted by SLC Mom at 12:30 PM on September 14 [2 favorites]

I'd pick Metformin if it's already working for you. I did well on it with no side effects. I also love Metformin's very long track record of safe use. This drug has been used for decades and I find that far more comforting than the latest shiny, expensive thing that arrives without equivalent piles of data showing no surprise, long-term, negative effects.
posted by quince at 12:45 PM on September 14 [4 favorites]

Congratulations on your progress! Please consider a second opinion via telehealth/telephone, as early, aggressive treatment in metabolic disorders like Type II diabetes preserves long-term health. Recent Trulicity (generic: dulaglutide, a GLP-1 receptor agonist) study and news; metformin vs. trulicity chart.

My uncle has insulin-dependent Type II diabetes, and started dulaglutide a little over two years ago. It reduced the amount of insulin he takes and led to better daily blood glucose readings. His A1C is lower, too, and he's also lost weight, which has helped with his back and knee pain.
posted by Iris Gambol at 12:46 PM on September 14 [1 favorite]

If I go too high on my Metformin dose, I get bright orange diarrhea, so be ready for that as a possibility. Right now I'm on 1000mg twice a day, once in the morning and once at night. Also, I'm taking the regular formulation, as the ER extended release were not as effective as plain ordinary Metformin for me.

I had similar A1C numbers, and the thing that really brought it under control was when my primary care provider recommended that I see a specialist pharmacist. "He knows more about how all these drugs interact, and it will be helpful." It was! (Pharmacists are allowed to prescribe medication where I live-- Washington state USA.)

In addition to reducing my Metformin dose, the pharmacist put me on Glyburide, but was alert enough to switch me off of it when a study showed it has some unpleasant side effects. He replaced it Glipizide, which does similar stuff but not in a dangerous manner.

But for me the real game changer for my A1C was adding Jiardiance (Empagliflozin) into the mix. Originally a heart medication, it has a beneficial side effect of making your body eliminate sugar through urine when you have too much in your system. This also has a (nice?) Pavlovian effect of letting you recognize when your diet is poor because you are going to the bathroom so much more frequently. I believe this is the drug that has done the most to bring my blood sugar down, even though I often still make poor food choices.

OK, so that's my experience in a similar situation. Ask your doctor if any of those other meds are an option for you, or if your health care system will let you see a pharmacist as well. It made a world of difference for me. Good luck!
posted by seasparrow at 1:11 PM on September 14 [1 favorite]

When I got officially diagnosed with T2, my HbA1c was 10.x. I took Metformin 1000 twice a day and over a few months it came down to 7.x. This was accompanied with weight loss (around 10 kg) and loss of visceral fat I think. But HbA1c stopped going down and my doctor prescribed Synjardy. I believe that is Empagliflozin + Metformin. Same dosage as before, but for a year or two now my HbA1c hovers around 5.5 - 6.5. I have lost a few more kilos, (and gained it), with more physical activity. Sometimes I forget to take a morning or evening dose, but it's been ok so far (only went up in response to stress).
In Austria most medicines are subsidized, so I don't know whether this dictates what medicines I receive.
posted by ssri at 1:36 PM on September 14 [1 favorite]

The second paragraph of this article states that Trulicity is equivalent to metformin.

Just a gentle heads-up that Iris Gambol's link leads to a single arm (read: no comparator) study published by the makers of Trulicity, and all the authors are either employees of the company that makes Trulicity, or subcontractors employed by same. It doesn't show that Trulicity is better than any other drug - only that it works.
posted by lulu68 at 2:07 PM on September 14 [1 favorite]

I am on both metformin and Victoza, and have been for several years - I started on metformin in about 1998 or so, when I was first diagnosed. I am on 2x500mg tablets twice daily. I have not been a good diabetic patient but I think the metformin has stopped things being much worse, and I am also cautiously hopeful about the additional(suggested, not as far as I know proven) health benefits metformin is supposed to have.

I used to know someone who was a very large person who developed diabetes around 2010. Two years or so passed and I saw them again and they had lost an appreciable amount of weight, through being prescribed Bydureon (I think) as a once a week injection.

I was prescribed Victoza because the metformin wasn't controlling the sugars well enough - not for any other reason than that I was not putting the work in. I lost about 45lb without much effort and am still on it. My sugars came down as well.

For me, I would be happy to stay on the metformin until such time as my kidneys really start to splutter. Metformin is quite hard on the kidneys and my dad was taken off it as his kidneys failed a few years back - but he'd been on it for about 50 years or so prior to that, with very little adverse impact.

My mum, on the other hand, hated metformin so much (upset stomach as described above) that she was taken off it. Unfortunately she was prescribed this as a replacement. It didn't end well.

So overall I would say if you are happy with the metformin and it's working, then stick with that as long as possible. Going up to the higher dose will take some getting used to and you will probably feel pretty yucky for a while (nausea, upset bowels and gas) but it is quite safe in my experience. Adding something like a GLP-1 analogue will help you lose weight and as a result you will probably find you need less metformin, and so it goes on more positively.

As an aside, I am also on insulin, for the full set of treatments, and that makes me a bit cross - many years ago I mentioned in passing wanting to start a family and I was sent to the pre-conception clinic and put on insulin. No family and 20 years later, I'm still on it and really don't want to be. But when I asked about stopping it, I was told that was a bad idea. So I would definitely try and stay off insulin if you can - I put on a lot of weight with it that I am only now starting to shift through a concerted effort.
posted by Martha My Dear Prudence at 3:05 PM on September 14

lulu68, it's a retrospective observational study, pulling data from the HealthCore Integrated Research Database (an "NIH Collaboratory Distributed Research Network" -- medical records from the largest for-profit managed health care company in the Blue Cross Blue Shield Association, Anthem), and its limits are disclosed in the paper?

Trulicity (dulaglutide/other brand names) isn't considered "equivalent" to metformin (the goodrx page in lulu68's link is from 2018). The big Researching Cardiovascular Events With a Weekly INcretin in Diabetes (REWIND) trial (a multi-year, international, double-blind randomized controlled trial which enrolled 9,901 people, age 50 and older with T2D from 24 countries at 371 care centers) showed "Dulaglutide Reduces Cardiovascular Disease in People with Type 2 Diabetes" (American Diabetes Association, 2019). Of course, that clinical trial was also underwritten Eli Lilly and Co.

davidstandaford, since your doctor is "pushing the Trulicity hard," they may be identifying other factors that make the drug superior to metformin alone in your treatment plan -- though right now, it may feel uncomfortably like 1) they're not acknowledging your hard work and good results over these months, and/or 2) they're abruptly moving the goalposts, and/or 3) they're an industry shill. It's somewhat concerning that "diabetes" doesn't appear in your question or tags. I'm not trying to make you uneasy; I'm just a former diabetes-nonprofit worker related to several people with diabetes, strongly encouraging you to book additional professional consultations to best understand your specific health situation & options. Best wishes.
posted by Iris Gambol at 3:30 PM on September 14 [1 favorite]

It feels troubling to me that your doctor has given you only two options.

I've been on metformin (500 mg/day) and Janumet (Januvia 50mg/metforming 500) for 10 years. They're both oral meds. My A1C was 15.8 upon diagnosis. (Yeah, I know! They thought it was T1 at first.) After 8 weeks on long-acting insulin Lantus injections and metformin, it was down to 7.8; four weeks later, on just metformin and Janumet, it was down to 6.1 and has stayed in the low 6's since 2012.

[As we say in DiabetesSisters, my diabetes is not your diabetes. My weight wasn't an issue and I have no heart or kidney concerns; I'm a woman and I'd had unrelated medical problems a little over a year prior which may or may not have triggered me to go from a 5.4 to 15.8 A1C in 9 months. It also could have been extreme stress.]

I prefer tight control. Any time my endocrinologist and I want to discuss changing my meds (my A1C always goes up in the summer because I react badly to high temperatures), he lists off a series of three or more options -- different oral meds, injections, etc. Usually, he'll ask me if I'd like to make a change and I say I'd like to wait and see how things are at my next appointment (3-4 months later) and the situation has always resolved itself by then.

My point is that my endo would never limit my options to only two choices and he explains the pros and cons of each option. You don't mention if this is your primary or an endocrinologist, but if it's the former, I strongly encourage you to see an endocrinologist, as they are so much more adept and experienced at ALL the various options available. Even if you need to do a telehealth appointment, you want to talk to a doctor who deals with diabetes all day, every day, not someone for whom it's a one-in-many diagnosis.

If your doc is an endo, then I encourage you to ask, "Why Trulicity and not Ozempic, another Glucagon-like peptide 1 (GLP-1) receptor agonist? Why not Rybelsus? Why not consider a different/combination (oral) med like Janumet?" What specifically is your doc focused on other than your A1C? Trulicity may be the perfect med for you, but you deserve a medical consultation that gives ALL the possible information.

A reduction in A1C from 11.2 to 8 is excellent, but it's only part of the equation. I don't (and you probably don't) know how long you were up in the 11s, and your doctor may be concerned about protecting various organs and protecting against stroke, heart attack, cardiovascular disease; or your doctor may be prescribing the next shiny thing his pharma rep brings in. You deserve a doctor who will be your partner in the decision-making process and bring .
posted by The Wrong Kind of Cheese at 6:09 PM on September 14 [4 favorites]

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