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No clear evidence metformin influences patient\u2010important outcomes [Cochrane Review (2020) of 18 RCTs (<jats:italic>n<\/jats:italic>\u2009=\u200910\u2009680)].<\/jats:p><jats:p><jats:bold>R<\/jats:bold>isks: Inexpensive, essential WHO list drug; use contraindicated\/not tolerated in 15%: for example, contraindication: lactic acidosis in renal impairment (eGFR &lt;30\u2009mL\/min\/1.73\u2009m<jats:sup>2<\/jats:sup>).<\/jats:p><jats:p><jats:bold>A<\/jats:bold>dverse effects: Common gastrointestinal (GI) side effects are dose\u2010related and include abdominal pain, decreased appetite, diarrhoea (usually transient), nausea and vomiting, altered taste; vitamin B<jats:sub>12<\/jats:sub> deficiency. Rare: acute metabolic acidosis (lactic acidosis\/diabetic ketoacidosis).<\/jats:p><jats:p><jats:bold>I<\/jats:bold>nteractions (pharmacokinetic) occur with drugs impairing renal function and hence metformin excretion, and drugs inhibiting organic cation transporter 1 or 2 (OCT1, OCT2), and\/or multidrug and toxin extrusion protein 1 (MATE1\/2\u2010K), such as cimetidine, ranolazine, trimethoprim and verapamil, and inducers such as rifampicin. The risk of hypoglycaemia may increase when metformin is used in combination with other medications for diabetes (pharmacodynamic interaction).<\/jats:p><jats:p><jats:bold>N<\/jats:bold>ecessary prophylaxis: Detect\/treat vitamin B<jats:sub>12<\/jats:sub> deficiency.<\/jats:p><jats:p><jats:bold>S<\/jats:bold>usceptible groups: Elderly\/renal\/liver impairment (lactic acidosis); safe in pregnancy\/breastfeeding.<\/jats:p><jats:p><jats:bold>A<\/jats:bold>dministering: Initially 500\u2009mg once daily (morning) with breakfast; titrate only after 1\u2009week.<\/jats:p><jats:p><jats:bold>I<\/jats:bold>nforming (relevant BRAINS &amp; A(I)MS principles).<\/jats:p><jats:p><jats:bold>M<\/jats:bold>onitoring: Renal function beforehand, and 6\u201312 monthly, HbA1c 3\u20136 monthly until controlled. Serum vitamin B<jats:sub>12<\/jats:sub> levels if deficiency is suspected\/risk factors for.<\/jats:p><jats:p><jats:bold>S<\/jats:bold>topping: Encourage patients to continue medication, unless deteriorating renal\/liver function. Reasons for deprescribing: no harms from stopping suddenly.<\/jats:p>","DOI":"10.1111\/bcp.15653","type":"journal-article","created":{"date-parts":[[2022,12,28]],"date-time":"2022-12-28T07:49:26Z","timestamp":1672213766000},"page":"931-938","source":"Crossref","is-referenced-by-count":6,"title":["Metformin\u2014\u2018BRAINS &amp; AIMS\u2019 pharmacological\/prescribing principles of commonly prescribed (Top 100) drugs: Education and discussion"],"prefix":"10.1111","volume":"89","author":[{"given":"Joshua","family":"Koslover","sequence":"first","affiliation":[{"name":"King's College London GKT School of Medical Education  London UK"},{"name":"West Hertfordshire Teaching Hospitals NHS Trust (Watford General Hospital)  Watford UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Deborah","family":"Bruce","sequence":"additional","affiliation":[{"name":"King's College London GKT School of Medical Education  London UK"},{"name":"Guy's and St Thomas' NHS Foundation Trust  London UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Shivani","family":"Patel","sequence":"additional","affiliation":[{"name":"King's College London GKT School of Medical Education  London UK"},{"name":"King's College Hospital NHS Foundation Trust  London UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8109-1877","authenticated-orcid":false,"given":"Andrew J.","family":"Webb","sequence":"additional","affiliation":[{"name":"Guy's and St Thomas' NHS Foundation Trust  London UK"},{"name":"Department of Clinical Pharmacology, King's College London British Heart Foundation Centre School of Cardiovascular and Metabolic Medicine and Sciences  London UK"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"311","published-online":{"date-parts":[[2023,1,23]]},"reference":[{"key":"e_1_2_7_2_1","volume-title":"Oxford Specialty Training: Revision Texts","author":"Webb AJ","year":"2020"},{"key":"e_1_2_7_3_1","article-title":"Introducing \u2018BRAINS & AIMS\u2019 pharmacological\/prescribing principles and their application to commonly prescribed (top 100) drugs: an education & debate series","author":"Webb A","year":"2023","journal-title":"BJCP"},{"key":"e_1_2_7_4_1","doi-asserted-by":"publisher","DOI":"10.1111\/bcp.13709"},{"key":"e_1_2_7_5_1","doi-asserted-by":"publisher","DOI":"10.1111\/j.1365\u20102125.2010.03823.x"},{"key":"e_1_2_7_6_1","doi-asserted-by":"publisher","DOI":"10.1111\/bcp.14320"},{"key":"e_1_2_7_7_1","doi-asserted-by":"publisher","DOI":"10.1172\/JCI13505"},{"key":"e_1_2_7_8_1","doi-asserted-by":"publisher","DOI":"10.2337\/dci15\u20100013"},{"key":"e_1_2_7_9_1","doi-asserted-by":"publisher","DOI":"10.1111\/j.1365\u20102125.1981.tb01206.x"},{"key":"e_1_2_7_10_1","unstructured":"British National Formulary BNF.https:\/\/bnf.nice.org.uk\/drugs\/metformin-hydrochloride\/. 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