Metformin Alternative: Practical Options if Metformin Isn't Right for You

Can’t tolerate metformin or need something more? You're not alone—gut upset, kidney limits, or pregnancy can make metformin a poor fit. The good news: there are proven alternatives, both drugs and lifestyle steps, that can help lower A1c and improve health. Below I lay out clear options and what to mention to your clinician.

Medication alternatives — what they do and when they make sense

GLP-1 receptor agonists (e.g., semaglutide, liraglutide). These injectables lower A1c and often cause weight loss. Good if you need weight control and heart benefits. Common downsides: nausea at first and cost/insurance hurdles.

SGLT2 inhibitors (e.g., empagliflozin, canagliflozin). They lower blood sugar by helping the kidneys remove glucose. Benefits include weight loss and reduced heart failure risk in some people. Not ideal if you have active genital infections or very low kidney function.

DPP-4 inhibitors (e.g., sitagliptin). Pills that modestly lower A1c with low risk of low blood sugar and few side effects. They’re a mild, well-tolerated step-up if metformin isn’t tolerated.

Sulfonylureas (e.g., glipizide). Cheap and effective at lowering sugar but raise the chance of low blood sugar and can cause weight gain. Often used when cost is the main issue and close monitoring is possible.

Thiazolidinediones (pioglitazone). These improve insulin sensitivity and can help some people with fatty liver or insulin resistance. Watch for weight gain, fluid retention, and rare bone issues.

Alpha-glucosidase inhibitors (acarbose). Slows carbohydrate absorption to blunt post-meal spikes. Side effects often include gas and bloating, so tolerance varies.

Insulin. When pills aren’t enough, short or long-acting insulin reliably lowers blood sugar. It requires training on dosing and monitoring but works for nearly everyone when needed.

Non-drug options and how to pick the right path

Diet and weight loss: A low-carb or Mediterranean-style diet can cut glucose and A1c quickly. Even 5–10% weight loss improves insulin sensitivity. Pair food changes with regular walking or strength training—exercise improves glucose control independent of weight loss.

Bariatric surgery: For people with obesity and high A1c, surgery can dramatically lower blood sugar and sometimes put diabetes into remission. It’s a major step and needs long-term follow-up.

Practical checklist for your next visit: bring your recent A1c and kidney function numbers, list of side effects from metformin, coverage/cost limits, and goals (weight loss, fewer hypos, pregnancy plans). Ask about monitoring frequency, possible side effects, and whether dose changes or combination therapy makes sense.

Want a quick takeaway? If metformin isn’t working for you, options exist that target weight, heart risk, or low hypoglycemia risk. Talk specifics with your clinician—matching the drug to your health goals matters more than the name on the pill.