11/13/24, 8\:19 PM Guide | Metformin counselling

Metformin counselling

Table of contents

Opening the consultation

Wash your hands and don PPE if appropriate.
Introduce yourself to the patient including your name and role.
Con
Clarify the purpose of the consultation\:
“ T o d a y y o u a r e h e r e t o d i s c u s s a m e d i c a t i o n c a l l e d m e t f o r m i n . I s t h a t c o r r e c t ?”
.
It is important to establish a good rapport and an open line of communication with the patient early in the consultation\:
h a v e a n y q u e s t i o n s a t a n y p o i n t – o r i f s o m e t h i n g i s n o t c l e a r – p l e a s e f e e l f r e e t o i n t e r r u p t a n d a s k m e”
.
“ I f y o u
Make sure to check the patient’s understanding at regular intervals throughout the consultation and provide opportunities to
ask questions (this is often referred to as ‘chunking and checking’).

Ideas, concerns & expectations

A key component of counselling involves exploring a patient’s ideas, concerns and expectations (often referred to as ICE).
Asking about a patient’s ideas, concerns and expectations can allow you to gain insight into how a patient currently perceives
their situation, what they are worried about and what they expect from the consultation. It can sometimes be challenging to use
the ICE structure in a way that sounds natural in your consultation, but we have provided some examples for each of the three
areas below.
Ideas
“ H a v e y o u h e a r d o f m e t f o r m i n ?”
“ B e f o r e w e s t a r t , w h a t d o y o u a l r e a d y k n o w a b o u t m e t f o r m i n ?”
“ D o y o u k n o w w h a t m e t f o r m i n i s u s e d f o r ? ”
Concerns
“ I s t h e r e a n y t h i n g t h a t w o r r i e s y o u a b o u t t a k i n g m e t f o r m i n ?”
Expectations
" I s t h e r e a n y t h i n g s p e c i
“ W h a t a r e y o u h o p i n g t o g e t o u t o f t h i s c o n v e r s a t i o n a b o u t m e t f o r m i n ?”
Tip\: Establishing the patient’s ideas, concerns and expectations early in the consultation will enable you to focus on the factors
that matter most to the patient. This will increase the quality of the consultation and further build rapport between you and the
patient.

Patient history

Although the purpose of this station is to counsel the patient, it is a good idea to gather a quick, focused history early in the
consultation.
This should include an exploration of the patient’s symptoms and management of their condition, including trials of previous
medications, including their impact, compliance and adverse e
contraindications and cautions, other medications the patient is taking, smoking and pregnancy.
https\://app.geekymedics.com/osce-guides/counselling/metformin-counselling/ 1/711/13/24, 8\:19 PM Guide | Metformin counselling
Understanding the patient’s care so far will help you tailor any advice and personalise the information for their speci
situation.

Allergies

Ask the patient if they have any known allergies. If the patient has had a drug reaction previously, ask about the features and
severity of the reaction.
An individual's drug allergy status should be documented in their medical records, and this information should be kept distinct
from the details of any adverse drug reactions.
1
“ A r e y o u a l l e r g i c t o a n y m e d i c a t i o n s ?”
“ H a v e y o u r e a c t e d t o a n y m e d i c a t i o n s i n t h e p a s t ?”

Contraindications and cautions for metformin

Screen for any contraindications to metformin. Metformin should not be prescribed to patients at risk of lactic acidosis\:
2,3,4
Diabetic ketoacidosis (DKA)
Hepatic insu
Risk of acute kidney injury (e.g. hypovolaemia, shock)
eGFR \<30
Acute alcohol intoxication
Any cause of tissue hypoxia\: cardiac or respiratory failure, shock, recent myocardial infarction.
Metformin should be withdrawn if these conditions develop.
2,3,4
Screen for any cautions to prescribing metformin\:
Risk of renal impairment (e.g. on nephrotoxic drugs)
In addition, metformin should be prescribed with caution in elderly people.
2
“ D o y o u k n o w o f a n y r e a s o n w h y y o u m a y n o t b e a b l e t o t a k e m e t f o r m i n ?”
“ D o y o u h a v e a n y p r o b l e m s w i t h y o u r k i d n e y s o r l i v e r ?”

Drug history

An accurate drug history is essential to identify potential drug interactions.
Medications which may interact with metformin include\:
Corticosteroids
Diuretics (e.g. furosemide)
Beta-blockers
Hormone replacement therapy\: oestrogen, progesterone, testosterone
Ask if the patient is taking any insulin or other anti-diabetic medications, as the risk of hypoglycaemia can be increased when
metformin is used in combination.
2, 5, 6
“ A r e y o u c u r r e n t l y t a k i n g a n y r e g u l a r m e d i c a t i o n s o r o v e r-t h e-c o u n t e r m e d i c i n e s ?”
“ A r e y o u t a k i n g a n y o t h e r d r u g s f o r y o u r d i a b e t e s , o r a r e y o u o n i n s u l i n ?”

What is metformin and when is it used?

Metformin is a biguanide anti-hyperglycaemic drug. It is used as
combined with other oral anti-diabetic drugs or insulin.
Metformin lowers blood glucose concentrations without causing hypoglycaemia.
Metformin can also be used in the treatment of gestational diabetes, type 2 diabetes in children (aged >8) and polycystic
ovary syndrome (unlicensed).
2,7,10,11,12,13
“ M e t f o r m i n i s a l o n g-t e r m t r e a t m e n t u s e d t o m a n a ge y o u r d i a b e t e s b y h e l p i n g c o n t r o l y o u r b l o o d s u ga r l e v e l s . M e t f o r m i n i s
u s u a l l y t h e
s u g a r l e v e l s t o d r o p t o o l o w .
”
https\://app.geekymedics.com/osce-guides/counselling/metformin-counselling/ 2/711/13/24, 8\:19 PM Guide | Metformin counselling

How does metformin work?

Type 2 diabetes

cells.
Insulin is a hormone made by the pancreas which regulates blood glucose levels, acting as a ‘key’ allowing glucose to enter
Type 2 diabetes is characterised by an insensitivity to insulin (‘insulin resistance’). Instead of entering cells, glucose (sugar)
remains in the bloodstream causing high blood sugar levels (hyperglycaemia).
High blood sugar cause symptoms (e.g. thirst, tiredness, and polyuria). Over extended periods, high blood sugar can cause
damage to organs, blood vessels and nerves.
10,11,13
For more information, see our OSCE guide to explaining a diagnosis of diabetes.

How metformin works

Metformin primarily lowers blood glucose concentrations by reducing hepatic glucose production (called gluconeogenesis)
and increasing the ‘insulin sensitivity’ of peripheral tissues, increasing glucose uptake and utilisation.
7,10,14
Metformin does not stimulate insulin secretion, so it does not cause hypoglycaemia.
7,10,14
The mechanisms underlying these e
monophosphate-activated protein kinase (AMP kinase).
10
“M e t f o r m i n l o w e r s y o u r b l o o d g l u c o s e l e v e l s . I t d o e s t h i s b y r e d u c i n g gl u c o s e ( s u ga r ) r e l e a s e d b y t h e l i v e r i n t o t h e b l o o d a n d
i n c r e a s i n g g l u c o s e ( s u g a r ) u p t a k e b y t h e c e l l s i n y o u r b o d y .
”
“ I t i s i m p o r t a n t t o c o n t r o l y o u r b l o o d s u ga r l e v e l s a s h i g h b l o o d s u ga r o v e r l o n g p e r i o d s c a n d a m a g e y o u r n e r v e s a n d b l o o d
v e s s e l s . T h i s c a n p r e s e n t a s l o s s o f f e e l i n g o r p a i n i n y o u r
i n c r e a s e d r i s k o f s t r o k e .
”

How to take metformin

Metformin comes in tablet, liquid and powder forms. It is usually prescribed as a tablet.
15
Metformin should be taken at the same time(s) each day. It should be taken with a meal or just after. This will improve
gastrointestinal tolerability.
Starting doses of metformin vary, but generally, patients are started on lower doses, which are then titrated to reduce the risk
of side e
A common example regimen when starting metformin is 500mg once daily with breakfast.
2,7,16
“ M e t f o r m i n i s u s u a l l y g i v e n i n t a b l e t f o r m . I t s h o u l d b e t a k e n a t t h e s a m e t i m e e a c h d a y w i t h f o o d o r j u s t a f t e r e a t i n g.”
“ W h e n y o u s t a r t m e t f o r m i n , t h e d o s e w i l l b e i n c r e a s e d s l o w l y . T h i s w i l l r e d u c e t h e c h a n c e o f s i d e e
”

Duration of treatment

Metformin is a long-term medication, and diabetes treatment is usually for life. The patient's blood sugar levels will be
checked regularly, and the metformin dose may be adjusted accordingly.
16
“ T r e a t m e n t o f d i a b e t e s i s l i f e-l o n g . A f t e r b e i n g p r e s c r i b e d m e t f o r m i n , y o u w i l l l i k e l y b e t a k i n g t h i s l o n g-t e r m . W e m a y n e e d t o
c h a n g e y o u r m e t f o r m i n d o s e d e p e n d i n g o n y o u r b l o o d s u ga r l e v e l s”
.

Types of metformin

Metformin comes in two forms\: standard release and slow-release or modi
same way but have di
Patients with troublesome gastrointestinal side e
metformin.
https\://app.geekymedics.com/osce-guides/counselling/metformin-counselling/ 3/711/13/24, 8\:19 PM Guide | Metformin counselling
Modi
gastrointestinal side e
and fewer side e
16,17
“ S o m e p e o p l e
”
I t c a n u p s e t t h e s t o m a c h . I f t h i s i s t h e c a s e , w e c a n

Missed doses

After a missed dose, patients should take the next dose as normal when it is due. Patients should not take two doses together
to compensate for a forgotten dose.
16
“ I f y o u m i s s a m e t f o r m i n d o s e , d o n’ t t a k e t w o d o s e s t o g e t h e r t o m a k e u p f o r t h i s . C o n t i n u e t o t a k e t h e n e x t d o s e a s n o r m a l .
”

Metformin monitoring

Renal function should be checked before starting metformin. If eGFR is less than 30, metformin should not be initiated.
During treatment with metformin, patients with normal renal function should have their eGFR checked annually. Patients at risk
of renal impairment should have their eGFR checked twice a year.
2, 7
“ B e f o r e s t a r t i n g m e t f o r m i n , y o u w i l l n e e d a b l o o d t e s t t o c h e c k y o u r k i d n e y f u n c t i o n . T h e r e a f t e r , y o u r k i d n e y f u n c t i o n w i l l b e
c h e c k e d a t l e a s t a n n u a l l y .
”

What are the side e

Like all medicines, there are side e
patients about the signs associated with serious side e
Common side e2,7,10,18
Gastrointestinal upset
Gastrointestinal side e
Symptoms may include\:
Nausea
Vomiting
Diarrhoea
Abdominal pain
Taste disturbance
“ S o m e s i d e e
Weight loss
One of the bene
overweight and obese patients.
4,10,14,19
“ M e t f o r m i n d o e s n o t c a u s e w e i g h t ga i n , a n d i n s o m e p a t i e n t s , i t c a n c a u s e w e i g h t l o s s”
.

Rare but serious side e

B12 de
Long-term use of metformin, particularly at higher doses, can lead to B12 de
anaemia or neurological symptoms.
14,18
“ T a k i n g m e t f o r m i n f o r a l o n g t i m e c a n c a u s e a d e
f a i n t , o r b e g i n e x p e r i e n c i n g a b n o r m a l s e n s a t i o n s l i k e p i n s a n d n e e d l e s , y o u s h o u l d s e e k m e d i c a l h e l p t o g e t y o u r B 1 2 l e v e l s
c h e c k e d”
.
For more information, see the Medicines and Healthcare products Regulatory Agency (MHRA) drug safety alert on metformin
and B12 de.
Lactic acidosis
https\://app.geekymedics.com/osce-guides/counselling/metformin-counselling/ 4/711/13/24, 8\:19 PM Guide | Metformin counselling
Lactic acidosis is a rare but potentially life-threatening condition. The onset is insidious with non-speci
nausea, vomiting, abdominal pain, diarrhoea, weakness, and lethargy.
Lactic acidosis is more likely to occur in speci
vomiting, fasting for surgery), chronic liver disease, hypoxia and alcohol use. Metformin should be stopped if the patient is at
risk of lactic acidosis.
2,4,7,10
“ S e e k u r g e n t m e d i c a l a d v i c e i f y o u d e v e l o p a n y s e r i o u s i l l n e s s , a s m e t f o r m i n m a y n e e d t o b e s t o p p e d d u e t o a r a r e a n d s e r i o u s
s i d e e
f e e l s i c k o r v o m i t . W h i l e t a k i n g m e t f o r m i n , d r i n k n o m o r e t h a n 2 u n i t s o f a l c o h o l p e r d a y a s a l c o h o l c a n i n c r e a s e t h e r i s k o f l a c t i c
a c i d o s i s .
”
Metformin should be withheld before and for 48 hours after any scan involving IV contrast media due to the increased risk of
renal impairment. This can subsequently lead to metformin accumulation and lactic acidosis.
2, 3, 4
“ B e f o r e a n y m e d i c a l s c a n s , i n f o r m t h e s t a
”
Hypoglycaemia
Unlike other anti-diabetic treatments (e.g. insulin), metformin does not cause hypoglycaemia.
However, if a patient is taking other treatments for diabetes, it is important to educate them about the signs and
symptoms of hypoglycaemia so they can recognise these early and act accordingly.
4, 10, 18
Typical symptoms of hypoglycaemia include\:
Hunger
Trembling or shaking
Sweating
Weakness
Confusion
Di
“ M e t f o r m i n d o e s n’ t u s u a l l y c a u s e l o w b l o o d s u g a r o r h y p o g l y c a e m i a . B u t y o u a n d y o u r f r i e n d s a n d f a m i l y s h o u l d b e
a w a r e o f t h e s i g n s s o t h e y c a n r e c o g n i s e a h y p o gl y c a e m i c e p i s o d e i f i t h a p p e n s . Y o u m a y f e e l h u n gr y , w e a k , s h a k y , h a r d t o c o n c e n t r a t e o r b e c o m e c o n f u s e d”
.

Lifestyle advice

Metformin works to control blood sugar levels in patients with type 2 diabetes. It is important to make the patient aware that
lifestyle changes will help manage their blood sugar levels and weight.
19
“ A l t h o u g h m e t f o r m i n i s a t r e a t m e n t f o r y o u r d i a b e t e s , y o u c a n a l s o h e l p c o n t r o l y o u r b l o o d s u ga r l e v e l s t h r o u g h a b a l a n c e d d i e t
a n d k e e p i n g a c t i v e .
”

Diet

Good nutrition is essential in the management of diabetes. Advise high-
(e.g. fruit & vegetables).
Patients should try to limit foods high in sugar and salt content. Starchy foods like potatoes, rice, pasta and bread can raise
blood glucose quickly. They have a high-glycaemic index and make it harder to manage diabetes. Other starchy foods like
wholegrain bread or brown rice have a low-glycaemic index and a
19,20 21
“ I n t y p e 2 d i a b e t e s , t h e r e’ s n o f o o d y o u c a n’ t e a t , b u t i t’ s i m p o r t a n t t h a t y o u r d i e t i s b a l a n c e d . E a t a v a r i e t y o f f r u i t , v e ge t a b l e s
a n d p u l s e s . T r y t o l i m i t s t a r c h y f o o d s l i k e p o t a t o e s , w h i t e b r e a d , a n d p a s t a , a s t h e s e c a n s p i k e y o u r b l o o d s u g a r . M i n i m i s e t h e
a m o u n t o f s u g a r , f a t a n d s a l t i n y o u r d i e t . I t' s i m p o r t a n t t o e a t a t r e g u l a r m e a l t i m e s a n d n o t t o s k i p m e a l s t o a v o i d a n y ‘ h y p o s .
”

Exercise

https\://app.geekymedics.com/osce-guides/counselling/metformin-counselling/ 5/711/13/24, 8\:19 PM Guide | Metformin counselling
Explain to patients that they should exercise regularly, aiming for about 150 minutes weekly. Regular exercise will lower blood
glucose levels, reduce cardiovascular risk, and help maintain a healthy weight.
19,22
“ Y o u s h o u l d t r y t o e x e r c i s e f o r a p p r o x i m a t e l y t w o a n d a h a l f h o u r s e a c h w e e k . R e gu l a r e x e r c i s e w i l l h e l p y o u m a i n t a i n a h e a l t h y
w e i g h t , c o n t r o l b l o o d s u g a r l e v e l s a n d r e d u c e y o u r r i s k o f h e a r t d i s e a s e , s t r o k e a n d c a n c e r .
”

Alcohol and smoking

The recommended alcohol limits are 14 units per week, spread over three or more days for both men and women. Advise the
patient that alcohol is high in calories, can interfere with their diabetes medication and make hypoglycaemic episodes less
obvious.
19, 23
“ Y o u s h o u l d d r i n k n o m o r e t h a n 1 4 u n i t s o f a l c o h o l p e r w e e k s p r e a d o v e r t h r e e d a y s o r m o r e . W h e n t a k i n g m e t f o r m i n , y o u
s h o u l d d r i n k n o m o r e t h a n t w o u n i t s p e r d a y . A l c o h o l i s h i gh i n c a l o r i e s , c a n i n t e r f e r e w i t h y o u r d i a b e t e s m e d i c a t i o n a n d m a y
m a k e h y p o g l y c a e m i c e p i s o d e s l e s s o b v i o u s .
”
If appropriate, advise the patient on the importance of smoking cessation and signpost to smoking cessation services.
19

Follow up

It is critical that patients attend follow-up appointments to review blood sugar control and screen for complications. Patients
newly diagnosed with type 2 diabetes will have their HbA1c checked every three months, then every six months after it's
stable.
Annually, patients with diabetes will have a ‘diabetic review’ including\:
19,24
Examining the feet ('foot check')
Diabetic retinopathy eye screening
Checking blood pressure
Blood tests\: cholesterol, renal function, HbA1c
“ P e o p l e w i t h t y p e 2 d i a b e t e s h a v e l o t s o f h e a l t h c h e c k -u p s a n d a p p o i n t m e n t s . I t i s i m p o r t a n t t h a t y o u a t t e n d t h e s e , a s t h i s i s
t h e b e s t w a y t o l o w e r y o u r r i s k o f c o m p l i c a t i o n s a n d h e l p y o u t o c o n t r o l y o u r b l o o d s u ga r . Y o u w i l l h a v e b l o o d s u ga r c h e c k s
( H b A 1 c ) e v e r y t h r e e m o n t h s a n d t h e n e v e r y s i x m o n t h s a f t e r t h e y' r e s t a b l e . A n n u a l l y y o u w i l l h a v e a ‘ d i a b e t i c r e v i e w’ t h i s w i l l
i n v o l v e h a v i n g a l o o k a t y o u r f e e t , c h e c k i n g f o r d a m a ge t o y o u r e y e s , b l o o d p r e s s u r e c h e c k s a n d b l o o d t e s t s t o l o o k a t y o u r
c h o l e s t e r o l a n d k i d n e y f u n c t i o n .
”

Closing the consultation

Close the consultation by summarising what you have discussed. This allows you to emphasise the key points of the
consultation.
Ask the patient if they have any questions or concerns that have not been addressed.
Finally, thank the patient for their time and o
Dispose of PPE appropriately and wash your hands.

Reviewer

Holly Elwell
Highly Specialist Pharmacist for Medical Education
Honorary Lecturer in Pharmacology and Prescribing Practice

References

1. Medscape UK. Drug allergy\: diagnosis and management. 2014. Available from\: [LINK]
2. NICE. Metformin. 2023. Available at\: [LINK]
3. NHS. Who can and cannot take metformin. 2022. Available at\: [LINK]
4. Nasri H, RaLINK]
https\://app.geekymedics.com/osce-guides/counselling/metformin-counselling/ 6/711/13/24, 8\:19 PM Guide | Metformin counselling
5. NHS. Taking metformin with other medications and herbal supplements. 2022. available at\: [LINK]
6. BNF. Metformin interactions. 2023. Available at\: [LINK]
7. BNF. Metformin hydrochloride. 2023. Available at\: [LINK]
8. GOV UK. Smoking and smoking cessation\: clinically signi
[LINK]
9. NHS. Pregnancy, breastfeeding and fertility while taking metformin. 2022. Available at\: [LINK]
10. Drug bank. Metformin. 2023. Available at\: [LINK]
11. NHS. About metformin. 2022. Available at\: [LINK]
12. NICE. Type 2 diabetes in adults\: choosing medicines. 2022. Available at\: [LINK]
13. NHS. Type 2 diabetes. 2020. Available at\: [LINK]
14. Diabetes UK. Metformin and diabetes. 2023. Available at\: [LINK]
15. BNF. Metformin hydrochloride medicinal forms. 2023. Available at\: [LINK]
16. NHS. How and when to take metformin. 2022. Available at\: [LINK]
17. Jabbour S, Ziring B. Advantages of extended-release metformin in patients with type 2 diabetes mellitus. 2011. Available at\:
[LINK]
18. NHS. Side eLINK]
19. NICE. Diabetes – type 2\: Scenario\: Management – adults. 2023. Available at\: [LINK]
20. Food and keeping active. 2020. Available at\: [LINK]
21. Diabetes UK. What is a healthy, balanced diet for diabetes?. 2023. Available at\: [LINK]
22. NHS.uk. BeneLINK]
23. NHS.uk. Going for regular check-ups. 2020. Available at\: [LINK]
24. NHS.uk Alcohol units. 2021. Available at\: [LINK]
Source\: geekymedics.com
https\://app.geekymedics.com/osce-guides/counselling/metformin-counselling/ 7/7