An evidence-based consensus report by the American Diabetes Association and European Association for the Study of Diabetes recommends metformin and comprehensive life- style optimization as first-line therapy.263 In patients with established ASCVD, including ischemic stroke, when prevention of further vascular events is the priority, GLP-1 receptor agonist therapy should be added to metformin independently of baseline HbA1c. When concern for heart failure or chronic kidney disease predominates, addition of a sodium- glucose cotransporter 2 inhibitor to metformin is recommended. These developments in manage- ment have implications for the care of patients with diabetes and ischemic stroke. Clinicians should now engage patients in a discussion of the new therapies and alternatives. Through shared decision-making, clinicians should help patients decide if a GLP-1 receptor agonist or a sodium- glucose cotransporter 2 inhibitor is right for them. Risk for future vascular disease is only one consid- eration in selecting among available diabetes med- ications. Cost, side effects, desire for weight loss, aversion to injection therapy, and desire to reduce risk for hypoglycemia are also important. 3. Optimal management of T2D is achieved with a multidimensional approach that includes (1) med- ical nutritional therapy; (2) lifestyle counseling (for physical activity, weight loss, smoking cessation, etc); (3) diabetes self-management, education, and support; and (4) medication therapy.263,264 For patients with overweight or obesity, it can be help- ful to include intensive behavioral counseling for weight loss in medical nutritional therapy. T2D in most patients is highly responsive to weight opti- mization; weight loss can result in diabetes remis- sion for some patients and reduced medication use in most. 4. 