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.

3rd Department of Internal Medicine 1st Faculty of Medicine Charles University 1 Ulice Nemocnice 128 08 Prague 2 Czech Republic

5th Medical Department With Endocrinology Rheumatology and Acute Geriatrics Vienna Health Association Clinic Ottakring 37 Montleartstraße 1160 Vienna Austria

Clinic for Endocrinology Diabetes and Metabolic Diseases Clinical Center of Serbia Faculty of Medicine University of Belgrade Belgrade Serbia

Clinic of Internal Diseases Family Medicine and Oncology Institute of Clinical Medicine Faculty of Medicine Vilnius University Vilnius Lithuania

Department of Diabetes Carol Davila University of Medicine and Pharmacy Bucharest Romania

Department of Diabetology National Medical Academy for Postgraduate Education Kiev Ukraine

Department of Endocrinology Diabetes and Metabolic Diseases University Medical Center Ljubljana 7 Zaloška Cesta 1000 Ljubljana Slovenia

Department of Endocrinology Medical University Sofia 2 Zdrave Street Sofia Bulgaria

Department of Internal Medicine 3 Astana Medical University 49A Beybitshilik Street Nur Sultan City Kazakhstan

Department of Internal Medicine and Oncology Semmelweis University 2 a Korányi Sándor Utca Budapest 1083 Hungary

Department of Nephrology Dialysis N C Paulescu National Institute for Diabetes Nutrition and Metabolic Diseases Bucharest Romania

Division of Endocrinology Diabetes and Metabolism University Hospital Basel Basel Switzerland

Division of Gastroenterology University Center for Gastrointestinal and Liver Diseases St Clara Hospital and University Hospital Basel Switzerland

Faculty of Medicine Josip Juraj Strossmayer University of Osijek Osijek Croatia

Head of Endocrinology Russian Medical Academy of Continuous Professional Education Ministry of Healthcare of the Russian Federation Moscow Russia

Institute of Diabetes Endocrinology and Metabolism Rambam Health Care Campus and the Bruce Rappaport Faculty of Medicine Technion P O Box 9602 3109601 Haifa Israel

Medical University of Vienna Vienna Austria

National Institute of Endocrinology and Diabetology Lubochna Slovak Republic

Riga East Clinical Hospital Riga Latvia

Riga Stradins University Riga Latvia

School of Medicine University of Zagreb Zagreb Croatia

Vuk Vrhovac University Clinic for Diabetes Endocrinology and Metabolic Diseases Merkur University Hospital Zagreb Croatia

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