6 Reasons Metformin Should NOT Be Prescribed in Prediabetes

Metformin is the most commonly prescribed first-line medication for type 2 diabetes, and in recent years, its use has crept into prediabetes care. But should it be?

As Dr Jedha outlined in episode 69 of the Type 2 Diabetes Talk podcast, medication is usually not necessary in prediabetes.

Dr Jedha’s views and experience are backed by science that shows there are strong reasons to challenge the routine prescription of metformin for prediabetes.

Here are six science-backed reasons why.

1. Most People with Prediabetes Never Develop Diabetes

The fear of a type 2 diabetes diagnosis often drives urgency to act. But it’s important to know the real risks.

About two-thirds of people diagnosed with prediabetes will not progress to type 2 diabetes, even after many years.

For example, in the Diabetes Prevention Program Outcomes Study, 65% of people in the placebo group had still not developed diabetes 5.7 years after the original trial ended. The Framingham Offspring Study echoed this, finding that nearly 70% did not progress to diabetes after 27–30 years.

If most people won’t get diabetes, it raises a critical question: why medicate millions who likely don’t need it?

As Dr Jedha clearly said in episode 69, prediabetes has become overmedicalized! Medication for most people with prediabetes, simply is not necessary.

Need help to achieve normal blood sugar? Join our Prediabetes Reset Program.

2. Up to One-Third Naturally Return to Normal Blood Sugar

Prediabetes is not a fixed condition. Multiple studies show that around 30–40% of people with prediabetes revert to normal glucose regulation without medication (known as prediabetes remission)—that’s often without prediabetes remission being the objective.

In the DREAM trial, 30% of people in the placebo group returned to normal within 3 years. In the Korean cohort study, 36% returned to normal glucose regulation within 10 years. Even in older adults, around 23% reverted to normal glucose levels.

These findings point to the dynamic nature of prediabetes—many people improve with time, especially with nutrition and lifestyle support.

3. Metformin Doesn’t Alter the Underlying Disease Process

The common claim is that metformin delays or prevents type 2 diabetes. But what’s actually happening is different. It helps to lower blood sugar below diagnostic thresholds while you’re taking it. Once the drug is stopped, the progression to diabetes resumes.

In other words, metformin suppresses blood sugar levels—it masks the symptoms—but doesn’t modify the underlying issues of insulin resistance or an altered metabolism.

Key takeaway: Medication masks the symptoms but does not treat the cause of prediabetes. Only food, nutrition and lifestyle can treat the cause to reverse prediabetes.

Need help to achieve normal blood sugar naturally? Join our Prediabetes Reset Program.

4. Any Gains Disappear After Metformin is Discontinued

In the Diabetes Prevention Program trial, when metformin was stopped, the number of people developing diabetes quickly returned to rates seen in the placebo group.

One might argue this proves it was working, but the real takeaway is that metformin does not provide lasting protection. Without continued use, the effect wears off, and people often end up back at square one.

This makes metformin a lifelong commitment without long-term benefit unless taken indefinitely.

Given Metformin puts people at risk of B12 deficiency, which can worsen blood sugar control and health outcomes, it hardly seems worth it when it’s not even necessary.

5. Cardiovascular Risk Isn’t Driven by Prediabetes Glucose Levels

Another common reason cited for early use of Metformin is the increased risk of cardiovascular disease in people with prediabetes.

But the evidence shows that it’s not the slightly elevated blood glucose that increases risk—it’s the associated factors like high blood pressure, abdominal obesity, inflammation, and high cholesterol levels.

Multiple studies have shown no independent association between prediabetes blood sugar and cardiovascular events or mortality. Therefore, reducing glucose levels with metformin will not meaningfully reduce cardiovascular risk.

You’re better off eating a healthy low carb diet for prediabetes, as it will improve your blood sugar, blood pressure, cholesterol, and overall heart health.

6. Cost, Side Effects, and Overmedicalization

Prescribing medications like metformin to over 80 million people with prediabetes in the U.S. alone would come with significant cost, not just financially, but psychologically.

Medicalizing a condition that often resolves naturally risks creating unnecessary anxiety, dependency, and side effects such as gastrointestinal discomfort and B12 deficiency.

It also detracts from the most effective and evidence-based approach: nutrition and lifestyle!

What Should Be Done Instead?

For people with prediabetes—those with fasting glucose levels between 110–125 mg/dL (6.1–6.9 mmol/L) or A1c levels between 5.7-6.4% (US) or between 6.0–6.4% (Canada, UK, Australia)—it makes sense to monitor more closely.

But even in these cases, the emphasis should first and foremost be on nutrition and lifestyle change: reducing excess carbohydrate intake, improving the quality of foods eaten, increasing physical activity, improving sleep and stress, and managing weight.

Medication should be reserved for when diabetes is actually diagnosed—and even then, only if non-drug strategies prove insufficient.

And most importantly, if a medication is prescribed at any point in time, that DOES NOT mean it needs to be taken forever!

Medications should be reviewed every 3-6 months—usually they aren’t.

The thing is, no matter how long you’ve had diabetes, and especially with prediabetes, you can get OFF medications!

Make sure you have that continuous conversation with your doctor about deprescribing medications, not just prescribing them!

Conclusion

Prediabetes is a warning sign, not a disease. While it’s important to take that warning seriously and get proactive about taking care of your health, medicating millions without strong evidence of benefit is not the answer.

The goal should be education, empowerment and effective support, not automatic prescriptions.

Metformin has a proven role in type 2 diabetes. But in prediabetes? The science says: not so fast!

Need help to achieve normal blood sugar? Join our Prediabetes Reset Program.

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