In the outpatient diabetes clinic at Jaramogi Oginga Odinga Teaching & Referral Hospital in Kisumu, the shelves where metformin tablets once sat are lined instead with glibenclamide, a sulphonylurea drug from a different era of diabetes care. The shift is not driven by clinical preference but by supply: persistent shortages of metformin, the globally recommended first-line agent for type 2 diabetes, have forced clinicians across Kenya to default to sulphonylureas as the initial oral therapy. The consequences are beginning to show in hospital data, and the move has reopened a long-simmering debate about what counts as first-line care when the first-line drug is simply not available.

Metformin Shortages Reshape First-Line Diabetes Care in Kenya

Metformin has been the cornerstone of type 2 diabetes management for decades. Its efficacy in reducing blood glucose without causing weight gain or significant hypoglycemia, combined with a favorable cardiovascular profile, earned it top billing in every major treatment algorithm. But in Kenya's public health system, the drug has become unreliable. Clinicians report that orders placed through the Kenya Medical Supplies Authority are frequently only partially fulfilled, and sometimes not at all. The shortages, which have worsened since 2023, are tied to global volatility in the price of metformin's active pharmaceutical ingredient, most of which is manufactured in China and India.

“We used to prescribe metformin as first-line without thinking twice,” says Dr. Grace Achieng, a diabetologist at the Kisumu hospital. “Now we have to check the pharmacy first. If metformin is out, we start patients on glibenclamide or gliclazide. It’s a clinical compromise that would be unacceptable in a high-income setting.” The situation is widespread: a survey of 20 public facilities across five counties, conducted by the Kenya Diabetes Management and Information Centre, found that metformin was out of stock at least one week per month in 14 of them. Some facilities had gone without for two consecutive months.

The scale of the problem is amplified by the rising burden of type 2 diabetes in Kenya. Roughly 500,000 adults are estimated to live with the condition, though many remain undiagnosed. The prevalence, around 2–4% in urban areas and lower in rural ones, is climbing with increasing obesity rates and aging populations. For a system already stretched by infectious disease priorities, a chronic drug shortage compounds the challenge of managing a condition that requires consistent, affordable medication.

Why Sulphonylureas Split Expert Opinion

Sulphonylureas have a long history in diabetes care. The UK Prospective Diabetes Study, published in the 1990s, showed that intensive glucose control with sulphonylureas reduced microvascular complications such as retinopathy and nephropathy. But the trial also hinted at a neutral or possibly adverse effect on cardiovascular outcomes, a finding that later meta-analyses have not fully resolved. Metformin, by contrast, demonstrated a cardiovascular benefit in overweight patients in the same trial, cementing its status as first-line in high-income guidelines.

Yet in many low- and middle-income countries, sulphonylureas remain widely used simply because they are cheap and available. A month's supply of glibenclamide costs roughly KSh 80 (about US$0.60), compared to KSh 200 for metformin when it is in stock. For patients paying out of pocket, the price difference matters. Some clinicians argue that the pragmatic choice—start a patient on a sulphonylurea today rather than wait for metformin to arrive—outweighs the theoretical advantage of metformin in a context where access trumps ideal algorithms.

“The evidence for metformin superiority is not absolute, especially in patients who are not overweight or who have normal kidney function,” says Dr. Samuel Omondi, a family physician working in a rural clinic in Siaya County. “If the choice is between sulphonylurea or no treatment at all, I’ll take sulphonylurea. But I worry about the elderly patients who end up with severe hypoglycemia because they can’t afford to test their blood sugar regularly.” That concern is at the heart of the controversy: sulphonylureas stimulate insulin secretion regardless of glucose level, and the risk of hypoglycemia is dose-dependent and unpredictable.

Kisumu Clinic Data Reveals Rising Hypoglycemia Admissions

Data from Jaramogi Oginga Odinga Teaching & Referral Hospital, shared with this reporter, show a clear trend. Hypoglycemia-related emergency room visits doubled in 2025 compared to 2023, with the majority of cases linked to glibenclamide use. Among patients over 65, the rate of severe hypoglycemia—defined as requiring intravenous glucose or hospital admission—was three times higher than among younger adults. Most of these patients had been started on sulphonylurea therapy within the prior six months, often because metformin was unavailable at the time of diagnosis.

“We are seeing people come in confused, sweaty, with blood glucose readings below 40 mg/dL,” says Dr. Achieng. “Some have irreversible neurological damage. This pattern has been documented in other low-resource settings; for instance, a 2022 study in Malawi reported a similar increase in hypoglycemia admissions after a switch from metformin to sulphonylurea. The mechanism is well understood: sulphonylureas have a long duration of action, and glibenclamide in particular accumulates in the elderly and in those with renal impairment, a common complication of long-standing diabetes.” The hospital has attempted to mitigate the risk by starting patients on the lowest possible dose of glibenclamide and advising them to skip doses if meals are skipped, but adherence to these instructions is low when patients cannot afford consistent glucose monitoring strips. A pack of 50 test strips costs around KSh 1,500, a prohibitive expense for many.

WHO Essential Medicines List Update Fuels Debate

The World Health Organization's Essential Medicines List, updated in 2023, includes metformin, glibenclamide, and insulin as options for type 2 diabetes but does not specify a preference hierarchy for first-line therapy. This neutrality reflects the reality that drug availability and cost vary dramatically across countries. Some experts argue the list should be more prescriptive to encourage countries to prioritize metformin. Others contend that the evidence base for first-line therapy has not changed and that the list appropriately leaves room for local adaptation.

Kenya's national essential medicines list and standard treatment guidelines follow the WHO lead, listing both metformin and glibenclamide as first-line options. “The guidelines are written with the assumption that both drugs are available,” says Dr. Peter Kilonzo, a pharmacist at the University of Nairobi. “But when one drug is chronically missing, the guideline becomes misleading. Clinicians are left to improvise.” The debate within Kenya's medical community is whether the national formulary should explicitly designate metformin as the preferred first-line agent and then provide a contingency protocol for shortages, rather than treating the two drugs as interchangeable.

Proponents of a more flexible approach point out that in many low- and middle-income countries, sulphonylureas have been the default for years without systematic evidence of harm at the population level. “We don't have the trials to show that metformin is better in this context,” says Dr. Omondi. “The UKPDS was done in a British population with a very different diet, body composition, and health system. It's not a direct translation.” Critics counter that the cardiovascular safety signal from metformin is robust enough to warrant prioritization, and that the rising incidence of hypoglycemia admissions is a warning sign that should not be ignored.

Local Manufacturers Offer Partial Solution

Kenya has at least one domestic manufacturer of metformin: Universal Corporation Ltd, based in Nairobi, produces the drug under the brand name Glucophage. But its production capacity meets only about 30% of national need, according to company estimates. The remainder is imported, and when global API prices spike or shipping delays occur, the supply chain buckles. Expanding local production is a logical response, but it faces regulatory and investment hurdles. The Pharmacy and Poisons Board requires rigorous bioequivalence studies for new generic entrants, a process that can take years and cost millions of shillings.

Sulphonylurea production, by contrast, is more scalable locally because the manufacturing process is simpler and the API is less expensive. Several Kenyan firms already produce glibenclamide tablets, and the supply chain is more resilient. This economic reality creates a perverse incentive: the drugs that are easiest to produce are not necessarily the best for patients. “We have to think about the entire system, not just what the guidelines say,” says Dr. Kilonzo. “If we can't guarantee metformin supply, then we need to invest in making it, or we need to train clinicians to use sulphonylureas as safely as possible.”

Price differences reinforce the status quo. A month of metformin costs a public facility roughly KSh 200, while a month of glibenclamide costs around KSh 80. For a county health budget that is already constrained, the cheaper option is tempting, even if it comes with hidden costs in emergency care. Some hospitals, such as Moi Teaching and Referral Hospital in Eldoret, have begun tracking hypoglycemia admissions as a quality indicator, but the data are not yet used to inform procurement decisions, according to a 2024 report from the Kenya Diabetes Management and Information Centre.

Clinicians Navigate Trade-offs Without Clear Guidance

Kenya does not have a national diabetes treatment algorithm that accounts for drug shortages. International guidelines from the American Diabetes Association and the European Association for the Study of Diabetes assume a stable supply of metformin and recommend it as initial therapy for nearly all patients. When that assumption fails, clinicians fall back on experience and local habit. In rural clinics, where access to specialist advice is limited, the default is often glibenclamide because it is what the pharmacy has.

Patients, too, adapt. Some switch between metformin and sulphonylurea depending on what is available at the time of refill, a practice that destabilizes glucose control. Others reduce their dose to avoid hypoglycemia, leading to hyperglycemia and complications. “I see patients who have been on three different drugs in six months because they just take what they can get,” says Dr. Achieng. “It's not diabetes management. It's survival.” The Kenya Diabetes Management and Information Centre has called for the development of adaptive national guidelines that include a shortage contingency algorithm, but the process has been slow.

The professional society's position is that metformin should remain first-line whenever possible, but that when it is unavailable, clinicians should start with a low dose of a shorter-acting sulphonylurea like gliclazide rather than glibenclamide, and provide clear instructions on glucose monitoring. Yet implementing this guidance requires resources—test strips, patient education materials, and follow-up—that are scarce. The trade-off between pragmatism and evidence is not theoretical; it plays out daily in consultation rooms across the country.

Steps Toward a Resilient First-Line Strategy

Several initiatives are under way to address the metformin supply gap. The African Medical Supplies Platform, a continental procurement mechanism, has begun negotiating pooled tenders for metformin API to stabilize prices for local manufacturers. Kenya's Ministry of Health has also announced plans to invest in a new API manufacturing facility, though timelines remain uncertain. In the interim, some hospitals are piloting fixed-dose combination tablets that contain both metformin and a sulphonylurea at a lower dose, aiming to reduce hypoglycemia risk while ensuring that patients receive at least some metformin.

Training programs are being redesigned to help clinicians adjust sulphonylurea doses more carefully. The Kenya Diabetes Management and Information Centre has developed a simple algorithm that recommends starting glibenclamide at 2.5 mg once daily for patients over 60 or with renal impairment, rather than the standard 5 mg, and titrating slowly. Point-of-care glucose test strips are being distributed to selected clinics through a donation program, but coverage remains patchy. “Every step helps, but none of this replaces a reliable supply of metformin,” says Dr. Kilonzo.

Yet some clinicians question whether these patchwork measures are sufficient. Dr. Omondi notes that even with careful dosing, the risk of hypoglycemia remains substantial without regular glucose monitoring, which many patients cannot afford. “We can train clinicians all we want, but if a patient can't test their blood sugar, a lower dose still carries risk,” he says. Others argue that the focus on sulphonylurea toxicity distracts from the larger issue of why metformin shortages persist in the first place. “We should be asking why a drug that costs pennies to make is not available,” says Dr. Achieng. “The solutions being proposed are bandaids. The real fix is supply chain reform.”

The situation in Kenya is not unique. Similar shortages have been reported in Uganda, Tanzania, and Nigeria, each with its own local dynamics. The challenge of maintaining first-line therapy in the face of drug shortages is not a static problem; it evolves with global markets, local production capacity, and health system priorities. As the data from Kisumu show, the consequences of supply failures are measurable in emergency room visits and patient outcomes. Whether Kenya can move from improvisation to a sustainable strategy remains an open question.

This article is for informational purposes only and does not constitute personalized medical advice. Individuals with diabetes should consult their healthcare provider for treatment decisions tailored to their specific circumstances and drug availability.