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In patients with chronic kidney disease, metformin may provide long\u2010term benefits, and it is a first\u2010line therapy for diabetes, but the estimated glomerular filtration rate (eGFR) must be assessed regularly, to minimize the risk for metformin accumulation. When eGFR is 30\u201060\u2009mL\/min\/1.73m\n                    <jats:sup>2<\/jats:sup>\n                    , the dose should be reconsidered, and sick\u2010days education provided. Metformin should be discontinued when eGFR falls below 30\u2009mL\/min\/1.73m\n                    <jats:sup>2<\/jats:sup>\n                    . Metformin accumulation may increase the risk for lactic acidosis if concomitant risk factors for hyperlactataemia (liver or respiratory insufficiency, sepsis, acute heart failure) are present; in these conditions, metformin is contraindicated, even although the available evidence is reassuring. Patients on metformin often complain of gastrointestinal side effects (mainly diarrhoea and nausea) during therapy initiation, but they may sometimes occur after years of stable therapy. These usually resolve if the dose is carefully titrated, or by switching to the extended\u2010release formulation. Patients with obesity may benefit from the significant, although modest, metformin\u2010associated weight loss and appetite reduction. During pregnancy, metformin is associated with a reduction of pregnancy complications, especially in obese women, but some concern remains, because metformin crosses the placenta, and it is associated with a significantly lower mean birth weight than insulin. In the elderly, gastrointestinal tolerability and renal function must be reassessed more often. Vitamin B\u201012 should be screened regularly in long\u2010time metformin users because metformin may induce clinical vitamin B\u201012 deficiency.\n                  <\/jats:p>","DOI":"10.1111\/dom.15749","type":"journal-article","created":{"date-parts":[[2024,7,11]],"date-time":"2024-07-11T00:59:10Z","timestamp":1720659550000},"page":"42-54","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":33,"title":["Optimizing metformin therapy in practice: Tailoring therapy in specific patient groups to improve tolerability, efficacy and outcomes"],"prefix":"10.1111","volume":"26","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-6695-3213","authenticated-orcid":false,"given":"Giovanni Antonio","family":"Silverii","sequence":"first","affiliation":[{"name":"Experimental and Clinical Biomedical Sciences \u201cMario Serio\u201d Department University of Florence  Florence Italy"},{"name":"Diabetology Unit Central Tuscany Local Health Unit  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