The accompanying Commentary notes that the study adds little to what is already known on this topic. Existing evidence is strong on the use of metformin as first-line therapy, and it should be used in patients without contraindications. A number of national guidelines recommend metformin as first-line therapy. Although the superiority of metformin as first-line therapy is not novel, the outcome of treatment intensification is not a commonly reported outcome and may be important to patients.
The NICE clinical guideline on type 2 diabetes recommends that metformin be started in a person who is overweight or obese and whose blood glucose is inadequately controlled by lifestyle interventions alone. Metformin should also be considered as an option for first-line glucose-lowering therapy for a person who is not overweight. A sulfonylurea should be considered as an option for first-line glucose-lowering therapy if the person is not overweight, the person does not tolerate metformin (or it is contraindicated), or a rapid response to therapy is required because of hyperglycaemic symptoms. Please see the link below for further details of the guidance.