The disclosure of proven cardiorenal benefits with certain antidiabetic agents was
supposed to herald a new era in the management of type 2 diabetes (T2D), especially
for the many patients with T2D who are at high risk for cardiovascular and renal events.
However, as the evidence in favour of various sodium-glucose transporter-2 inhibitor
(SGLT2i) and glucagon-like peptide-1 receptor agonists (GLP-1 RA) accumulates, prescriptions
of these agents continue to stagnate, even among eligible, at-risk patients. By contrast,
dipeptidyl peptidase-4 inhibitors (DPP-4i) DPP-4i remain more widely used than SGLT2i
and GLP-1 RA in these patients, despite a similar cost to SGLT2i and a large body
of evidence showing no clear benefit on cardiorenal outcomes. We are a group of diabetologists
united by a shared concern that clinical inertia is preventing these patients from
receiving life-saving treatments, as well as placing them at greater risk of hospitalisation
for heart failure and progression of renal disease. We propose a manifesto for change,
in order to increase uptake of SGLT2i and GLP-1 RA in appropriate patients as a matter
of urgency, especially those who could be readily switched from an agent without proven
cardiorenal benefit. Central to our manifesto is a shift from linear treatment algorithms
based on HbA1c target setting to parallel, independent considerations of atherosclerotic
cardiovascular disease, heart failure and renal risks, in accordance with newly updated
guidelines. Finally, we call upon all colleagues to play their part in implementing
our manifesto at a local level, ensuring that patients do not pay a heavy price for
continued clinical inertia in T2D.
