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Patients with moderate renal insufficiency received 50 mg daily of JANUVIA and those with severe renal insufficiency or with ESRD on hemodialysis or peritoneal dialysis received 25 mg daily

So docs basically have to absorb the liability and extra work while everyone else essentially gets the financial upside from the entire transaction

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Although these data do not entirely negate the argument that metformin mediates its anti-hyperglycemic actions via an inhibitory action on mitochondria complex 1, the evidence strongly suggests that further inhibition of function would worsen, and contribute to, the toxic effects of metformin, such as lactic acidosis, that are, albeit very rare ( quality-control regulation of mitochondria and shift the cellular dynamics to a healthy population via mitophagy and eliminate damaged mitochondria (138) [see also (148)]