Metformin alternatives

If metformin causes bad stomach problems, you have kidney limits, or it just doesn't lower your blood sugar enough, you don't have to stick with it. There are clear alternatives that work in different ways. Below I lay out common options, what they do, and simple things to watch for so you can talk to your clinician with confidence.

Common medication alternatives

SGLT2 inhibitors (empagliflozin, canagliflozin, dapagliflozin) help the kidneys remove extra glucose in urine. They often lower A1c moderately, can help with weight loss, and give heart and kidney protection for many people with type 2 diabetes. Watch for urinary tract and genital yeast infections, and a rare risk of ketoacidosis. They need attention if your kidney function is low.

GLP-1 receptor agonists (liraglutide, semaglutide and others) mimic a hormone that increases insulin after meals and slows stomach emptying. They usually lower A1c well and commonly cause weight loss. Side effects are mainly nausea and vomiting at first; some are injections, though oral semaglutide is available for some people. These drugs also show cardiovascular benefits for people with heart disease.

DPP-4 inhibitors (sitagliptin, linagliptin) are pills that modestly lower blood sugar and rarely cause low blood sugar. They’re well tolerated with few side effects, but they don’t help much with weight and lower A1c less than GLP-1s or SGLT2s.

Sulfonylureas (glipizide, glyburide) are older pills that boost insulin release. They work well to lower A1c and are inexpensive, but they can cause low blood sugar and weight gain. Good for short-term control or where cost is a big concern, but use carefully.

Thiazolidinediones (TZDs) like pioglitazone improve insulin sensitivity. They lower blood sugar reliably and are taken once daily, but they can cause fluid retention, weight gain, and are not ideal if you have heart failure.

Insulin remains the most powerful option to control high blood sugar fast. Different types and schedules exist—basal insulin at night or more complex regimens. Insulin causes weight gain and hypoglycemia risk, but it’s essential if A1c is very high or other drugs aren’t enough.

How to pick the right alternative

Ask these questions when you talk with your provider: What are my A1c and kidney numbers? Do I need weight loss or heart/kidney protection? What side effects am I willing to tolerate? Also check drug costs and whether your insurance covers the option. Start one change at a time, monitor blood sugar at home, and report severe side effects like fainting, trouble breathing, signs of infection, or symptoms of ketoacidosis (nausea, belly pain, fast breathing).

No single alternative fits everyone. The best one balances how much glucose lowering you need, other health goals (heart, weight, kidneys), safety for your kidneys, and cost. Bring this overview to your appointment and make a plan that matches your goals and daily life.