Bridging the gap in early cardio-renal risk prevention in type 2 diabetes: evidence, guidelines, and real-world insights from the PRECARE NO LiMITS initiative

Abstract Type 2 diabetes (T2D) is associated with a substantial burden of cardiovascular and renal complications. Although current evidence supports early implementation of organ-protective strategies, therapeutic inertia and uncertainty regarding guideline implementation may delay treatment intensification. The goal of this review is to discuss the rationale for early cardiorenal protection in T2D and to explore real-world perspectives on the use of SGLT2 inhibitors and GLP-1 receptor agonists through insights from the PRECARE NO LiMITS initiative. This narrative review integrates current evidence with exploratory findings from the PRECARE NO LiMITS project, a multicentre educational initiative involving diabetologists from ten diabetes centres in Lombardy, Italy. The initiative included two descriptive clinician survey rounds, conducted at baseline (T0) and after six months (T1), together with moderated expert discussions. At T1, a higher proportion of respondents reported considering SGLT2 inhibitor initiation in a greater proportion of patients with early cardiorenal risk markers, including albuminuria and mildly reduced eGFR, even in the absence of established cardiovascular or renal disease. Survey responses also suggested greater consideration of risk-based treatment strategies extending beyond glycaemic control alone. Persistent perceived barriers included reliance on HbA1c as a primary driver of treatment intensification, uncertainty regarding the timing and implementation of organ-protective therapies, and concerns related to treatment complexity and access. Given the descriptive nature of the survey, differences between T0 and T1 should be interpreted as exploratory. Overall, these exploratory observations, considered alongside current evidence and guideline recommendations, highlight the potential value of a proactive approach to T2D management focused on early identification of cardiorenal risk and appropriate consideration of organ-protective therapies. Educational initiatives, multidisciplinary collaboration, and improved translation of guideline recommendations into routine clinical practice may help address therapeutic inertia and facilitate timely, individualised treatment decisions.