01If the visit is on a screen, where does the bottle come from?
A video visit still ends at the same two steps. A clinician licensed where the person sits writes metformin. A pharmacy fills that written order. Mail-order and a local pickup both wait on that slip. Same-day stock is that pharmacy's inventory, not a promise in the video window.
The shop that offers metformin without a written order is not following the US label. A US phone number on a website does not replace the clinician or the pharmacy license. FDA tells people not to buy prescription tablets from sites that sit outside the United States or hide a physical address.
02What visit usually produces the first metformin bottle?
The visit that ends with metformin is a type 2 diabetes visit where glucose is high enough to treat and the kidneys still clear the drug. A primary-care clinician who already holds the chart can write the first line. Endocrinology is a second look when other diabetes medicines, a falling eGFR, or a messy glucose log need another pair of eyes.
The order names metformin or Glucophage. Either name can sit on the slip. The pharmacy fills the strength that arrived. Adult immediate-release tablets come as 500 mg, 850 mg, and 1000 mg. The metformin shelf on this site starts the talk at 500 mg.
03After the fill, who checks the next eGFR?
The same clinician who wrote the first line, or the clinician who took over the diabetes chart, redraws eGFR. If that number later falls below 45, the benefit and the risk of staying on metformin get a fresh look. If it falls below 30, the tablet stops. After a contrast hold, the restart waits on that 48-hour kidney read.
The pharmacy can ask about stomach start, meals, and alcohol when the bottle goes out. Those questions do not replace the kidney number on the chart. A written order that never comes back for eGFR is not the labelled follow-up.
04What does the first 500 mg line usually say?
Adult immediate-release metformin often opens at 500 mg twice daily with meals, or at 500 mg once daily, or at 850 mg once daily with a meal. The weekly climb, if glucose and the gut allow it, is a later visit. The first slip does not have to name 2550 mg. Totals above 2000 mg, when they come, may sit better as three meals rather than two.
The clinician who writes also plans the next eGFR. Annual kidney checks are the labelled floor. Older people, or anyone already close to 45, get those checks more often because clearance is already slower in that group.
05When does metformin stay unwritten?
The pen stays down when eGFR is already below 30. It also stays down in diabetic ketoacidosis and in anyone with a known metformin allergy. Hepatic disease on the chart is another reason clinicians hold the tablet, because lactate clearance is already impaired.
A planned iodinated contrast study can pause a tablet that is already in the bottle. Hold it at the time of, or before, contrast when eGFR is between 30 and 60, when liver disease, alcoholism, or heart failure is already listed, or when the contrast is intra-arterial. Recheck eGFR 48 hours later and restart only if kidneys are stable. That pause is not a way to start metformin. The over-the-counter question is a different URL.
06Which kidney number has to be on the chart?
EGFR is drawn before the first swallow. Metformin is contraindicated if eGFR is below 30 mL/min/1.73 m2. Starting when eGFR sits between 30 and 45 is a clinician call. The US label does not recommend a start in that band. A later fall below 45 gets a benefit-risk look. A later fall below 30 stops the tablet.
Hypersensitivity to metformin also blocks the order. So does acute or chronic metabolic acidosis, including diabetic ketoacidosis, with or without coma. Those stops live on the same contraindication list as the low eGFR line. The clinician who writes is the person who has seen that list, not a website cart.