Additionally, we would like to take this opportunity to provide a detailed commentary on the use of insulin in our study. Insulin therapy was administered to six of 36 patients whose HbA1c level remained at or above 7.0% after 24 months. Notably, in these six patients, HbA1c level was not well-controlled, with values of 12.9%±1.6% at baseline, 9.0%±1.4% at 12 months, and 11.1%±2.3% at 24 months. Despite these elevated HbA1c level, these patients did not exhibit hyperglycemic symptoms such as polyuria, polydypsia, or weight loss. For example, body weight increased over the treatment period: 72.6±30.4 kg at baseline, 74.5±33.4 kg at 12 months, and 77.8±34.0 kg at 24 months. Conversely, for the 30 patients who did not require insulin therapy, HbA1c level was relatively well-controlled (10.6%±1.6% at baseline, 7.2%±0.8% at 12 months, and 8.0%±1.1% at 24 months). They also did not present hyperglycemic symptoms, with stable weight (73.4±17.3 kg at baseline, 72.0±16.4 kg at 12 months, and 73.4±15.4 kg at 24 months) and no reports of polydipsia or polyuria.

We acknowledge the limitations of our study, as highlighted by our colleagues. Our research lacks a comparative arm with traditional sequential therapy or other combination therapies, and the potential for bias in subgroup analyses cannot be fully excluded. Additionally, the study population consisted exclusively of Korean patients from a single hospital, which may limit the generalizability of our findings. Nevertheless, there is a growing consensus on the superiority of triple combination therapy over stepwise therapy for achieving long-term durable glycemic control [2-5]. To solidify the role of this initial triple combination therapy as a viable strategy for drug-naïve patients with type 2 diabetes mellitus, we hope that future large-scale prospective studies will further validate the long-term efficacy and safety of this approach.