Core IM | Internal Medicine Podcast #192 Debate on First-Line Medications for Diabetes
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Nov 5, 2025 Kenneth Pfeiffer, a primary care physician and diabetes clinic co-director at Mount Sinai, defends GLP-1 receptor agonists for diabetes and obesity management. Keri Blum, also from Mount Sinai, highlights SGLT2 inhibitors as beneficial for heart and kidney health. Tracy Rabin, from Yale, emphasizes the practical use of metformin considering cost and tolerability. They delve into the complexities of choosing diabetes medications, weighing factors like A1c reduction, side effects, and patient-specific needs, including obesity and comorbidities.
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Start Metformin For Cost-Conscious Mild Diabetes
- Start metformin for newly diagnosed, mildly elevated A1c patients who prefer oral therapy and cost-sensitivity.
- Use extended-release formulation and titrate to effect while monitoring GFR above 45 ml/min/1.73m2.
Use SGLT2 Early For Renal Protection
- Consider an SGLT2 inhibitor early for patients with modest A1c needs and borderline kidney function to slow CKD progression.
- Check urine albumin-creatinine ratio to guide the decision.
Demo Injections To Overcome GLP-1 Hesitancy
- Offer GLP-1 agonists for patients motivated for weight loss or greater A1c reduction, and demonstrate injection technique to reduce hesitancy.
- Use demo pens or videos to increase acceptance of weekly injections.