Early Initiation of Sodium–Glucose Cotransporter-2 Inhibitor-Based Fixed-Dose Combinations in Type 2 Diabetes — an Indian Expert Consensus

Objective. To develop India-specific expert recommendations on the role of early initiation of sodium-glucose cotransporter-2 inhibitor (SGLT2i)-based fixed-dose combinations (FDCs) for the management of type 2 diabetes (T2D), with a focus on cardiorenal-metabolic risk reduction. Methods. A structured modified Delphi process was used. Consensus statements were voted on by 16 Indian endocrinologists/diabetologists in a single round using a 5-point Likert scale. Consensus was predefined as strong (≥ 75% agreement), moderate (60–74%), or weak (< 60%). Key findings/recommendations. Ten recommendations with strong consensus were finalized. The panel recommended early combination therapy over stepwise escalation for faster and more durable glycemic control and prioritized FDCs over loose-pill combinations to improve adherence. Sodium-glucose cotransporter-2 inhibitors were positioned as foundational therapy for people with T2D and elevated cardiovascular or renal risk irrespective of baseline hemoglobin A1c (HbA1c), supported by consistent reductions in heart failure hospitalization and slowing of chronic kidney disease progression. Earlier SGLT2i initiation (preferably within 12 months of T2D diagnosis) was favored to maximize cardiorenal benefit. Additional recommendations addressed a cardiorenal-metabolic approach to early treatment, a favorable safety profile (low hypoglycemia risk and no weight gain), potential benefits on glycemic durability/β-cell stress, and Indian cost-effectiveness considerations.