Is time ready for combination therapy at diagnosis of type 2 diabetes

Emerging evidence is showing a range of beneficial effects for GLP-1 receptor agonists and especially SGLT-2 inhibitors on the cardio-renal axis in patients with type 2 diabetes (T2D) and cardiovascular diseases (CVD). Preliminary findings suggest that: 1- such benefit extends also to patients with T2D without pre-existing CVD; and 2- background therapies do not modify the effect of these drugs. Given these considerations, some authors advanced the hypothesis that these novel agents might undermine the first-line position of metformin in the treatment algorithm of T2D. Here, we briefly discuss some pros and cons of such scenario, proposing a "starting" combination therapy with metformin plus one novel agent with trial-proven benefit as the best option to make use of the available knowledge and minimize the risk of complications in patients with newly diagnosed T2D.