1. Why this matters for MRCGP

• Type 2 diabetes is increasingly diagnosed in children, but type 1 diabetes should be assumed unless there are strong indications of type 2 diabetes. That is a classic AKT trap.
• The SCA risk is treating this like adult type 2 diabetes: reassurance, routine bloods, lifestyle advice and delayed follow-up are unsafe if diabetes is suspected.
• The GP’s key job is to recognise possible diabetes, assess for diabetic ketoacidosis or hyperosmolar hyperglycaemic state, and arrange the correct paediatric diabetes pathway.

2. GP Bottom Line

• Suspected diabetes in a child or young person is not routine adult-style type 2 diabetes care: assume type 1 diabetes unless there are strong indicators of type 2 diabetes.
• Suspected type 2 diabetes needs immediate same day referral to a multidisciplinary paediatric diabetes team to confirm diagnosis and provide immediate care.
• Unwell child, ketosis, dehydration, vomiting, drowsiness, confusion or breathing difficulty changes urgency: consider diabetic ketoacidosis or hyperosmolar hyperglycaemic state and arrange emergency admission to a hospital with acute paediatric facilities.
• Antidiabetic drug treatment is specialist-led: do not import adult type 2 diabetes drug algorithms into children and young people.

3. 60 Second Exam Snapshot

• In children and young people, assume type 1 diabetes unless strong type 2 indicators exist.
• Type 2 clues include obesity, strong family history, Black or Asian family background, and insulin resistance signs such as acanthosis nigricans.
• Symptoms may include polydipsia, polyuria, nocturia or enuresis, tiredness, blurred vision, weight loss, recurrent infections, behavioural change, reduced school performance or impaired growth.
• Suspected type 2 diabetes: same day multidisciplinary paediatric diabetes team referral.
• At diagnosis, specialist care includes dietary support, standard-release metformin, capillary blood glucose monitoring equipment, and insulin if HbA1c is 69 mmol/mol (8.5%) or more.
• Target HbA1c is 48 mmol/mol (6.5%) or lower, individualised to the lowest safely achievable target; measure every 3 months.
• Annual monitoring from diagnosis: hypertension, dyslipidaemia and albumin:creatinine ratio; retinopathy screening starts from age 12.

4. Recognition and Diagnosis

• Think diabetes when a child or young person has thirst, frequent urination, nocturia or enuresis, tiredness, blurred vision, unexplained weight loss, recurrent infections, reduced school performance, behavioural change or impaired growth. Symptoms may be mild or absent.
• Features that make type 2 diabetes more likely include obesity, strong family history of type 2 diabetes, Black or Asian family background, and evidence of insulin resistance such as acanthosis nigricans. Acanthosis nigricans is dark pigmentation in skin folds, typically the axillae, groin and neck.
• Do not let type 2 features falsely reassure you. Children and young people can present with diabetic ketoacidosis, and type 2 diabetes can also develop diabetic ketoacidosis.
• Persistent hyperglycaemia may be suggested by fasting plasma glucose 7.0 mmol/L or more, or random plasma glucose 11.1 mmol/L or more with symptoms or signs. However, HbA1c should not be used to diagnose diabetes in children and young people under 18 years.
• For GP exam purposes, the safe action is same day specialist confirmation, not GP diagnosis by HbA1c.
• Do not measure C-peptide or diabetes specific autoantibodies at initial presentation to distinguish type 1 from type 2 diabetes. Consider other diabetes types if diabetes occurs in the first year of life, ketones rarely or never occur during hyperglycaemia, or there are associated features such as optic atrophy, retinitis pigmentosa, deafness or another systemic illness.

5. AKT Essentials: What Changes the Answer

Diagnosis / recognition

• Assume type 1 diabetes unless strong indications of type 2 diabetes.
• Type 2 indicators include obesity, strong family history of type 2 diabetes, Black or Asian family background, evidence of insulin resistance, not needing insulin, or needing less than 0.5 units/kg/day after the partial remission phase.
• Do not use HbA1c to diagnose diabetes in under 18s.

Investigation / interpretation

• If diabetic ketoacidosis is suspected, check blood ketones if available.
• If blood ketone testing is not possible in a child or young person with suspected diabetic ketoacidosis, arrange immediate admission to acute paediatric facilities.
• If HbA1c monitoring is invalid because of disturbed erythrocyte turnover or abnormal haemoglobin type, estimate glucose trends using glucose profiles, total glycated haemoglobin if abnormal haemoglobins, or fructosamine.

Management / next best step

• Suspected type 2 diabetes: immediate same-day referral to a multidisciplinary paediatric diabetes team.
• Treatment should be initiated by the paediatric diabetes team.
• At diagnosis, paediatric diabetes team led care should include dietary management support, standard-release metformin, capillary blood glucose monitoring equipment, and insulin if HbA1c is 69 mmol/mol (8.5%) or more.
• If ketosis is present but diabetic ketoacidosis is not present, basal-bolus insulin should be offered by the paediatric diabetes team.

Medicines / safety

• Metformin is specialist-led in this age group. Standard-release metformin from diagnosis; NICE NG18 notes that formulations other than standard-release metformin were off-label in May 2023.
• In paediatric diabetes team-led care, they should offer liraglutide or dulaglutide from age 10, depending on preference, if the listed glucose or HbA1c criteria are met despite metformin.
• Empagliflozin may be considered from age 10 by paediatric diabetes team-led care if liraglutide or dulaglutide is not tolerated, or there is a clear preference for empagliflozin.
• Insulin can cause hypoglycaemia; insulin should not be stopped during intercurrent illness.

Follow-up / monitoring

• Review glucose monitoring data 4 weeks after diagnosis and starting metformin.
• Review treatment at least every 3 months.
• Measure HbA1c every 3 months.
• Screen annually from diagnosis for hypertension, dyslipidaemia and albuminuria.
• Refer for diabetic retinopathy screening from 12 years.

6. SCA Consultation Essentials

• This is likely to appear as a parent worried about thirst, bedwetting, weight change or tiredness; an adolescent with obesity and dark neck folds; or a known young person with type 2 diabetes who is vomiting or missing treatment.
• Gather the high-yield data: thirst, urination, nocturia or enuresis, weight loss, infections, blurred vision, tiredness, school performance, growth, abdominal pain, vomiting, breathing difficulty, drowsiness, confusion and dehydration. Ask about family history, ethnicity, weight, activity and any insulin resistance signs.
• The communication pivot is: “I am concerned this could be diabetes, and in children we need the paediatric diabetes team to confirm the type and start safe treatment today.”
• Do not make the consultation about blame or weight alone. Type 2 diabetes in children has psychological, family and school impacts. Ask sensitively about anxiety, depression, emotional and behavioural difficulties, eating disorders, family conflict and risk-taking behaviour.
• For post-pubertal young people where appropriate, include confidential sexual health, contraception and pre-pregnancy counselling. If pregnancy is possible, planned or confirmed, liaise urgently with the paediatric diabetes team and pregnancy diabetes services before changing diabetes medicines.
• If the young person is already diagnosed, ask about their care plan, contact details for the specialist diabetes team, medicines, insulin use, glucose monitoring, continuous glucose monitoring, hypoglycaemia, sick-day plan, school plan and missed appointments.
• Safety-netting must be specific: vomiting, inability to eat or drink, dehydration, persistent high or low glucose, significant ketones, drowsiness, confusion or breathing difficulty means urgent same-day help or emergency admission depending on severity.

7. Red Flags / Escalation / Referral

Immediate same-day referral

• Suspected type 2 diabetes in a child or young person: refer immediately to the multidisciplinary paediatric diabetes team.

Emergency admission to a hospital with acute paediatric facilities

• Suspected diabetic ketoacidosis.
• Suspected hyperosmolar hyperglycaemic state.
• Immediate risk of diabetic ketoacidosis, such as ketonaemia 1.5–2.9 mmol/L with or without hyperglycaemia, if the child cannot eat or drink.
• Suspected acute kidney injury that cannot be managed in primary care.
• An insulin-treated child or young person who does not show signs of clinical improvement with insulin treatment.

Consider admission or urgent specialist advice

• Unclear underlying illness.
• Dehydrated or at risk of dehydration.
• Vomiting persists beyond 2 hours, particularly in young children.
• Child younger than 3 years or has a co-existing medical condition.
• Family or carers cannot keep blood glucose above 3.5 mmol/L.
• Family or carers are exhausted, for example from repeated night-time waking.

Diabetic ketoacidosis features

• Polydipsia, polyuria, weight loss, abdominal pain, nausea or vomiting, shortness of breath, lethargy, drowsiness, confusion, fruity breath, Kussmaul breathing, tachycardia, dehydration or shock.

Hyperosmolar hyperglycaemic state features

• Hyperosmolar hyperglycaemic state is suggested by severe hyperglycaemia developing over days, marked dehydration or hypovolaemia, confusion or drowsiness, and no significant ketosis.

8. What the GP Should Do Today

Assess

• Decide whether this is suspected diabetes, known diabetes with intercurrent illness, or a possible hyperglycaemic emergency.
• Ask specifically about vomiting, abdominal pain, breathing difficulty, reduced consciousness, dehydration, inability to eat or drink, and ketone results if available.

Examine

• Assess hydration, consciousness, respiratory pattern, pulse and blood pressure.
• Look for acanthosis nigricans and growth or weight concerns, but do not delay referral.

Investigate

• If diabetic ketoacidosis is suspected, test capillary blood glucose and blood ketones if available.
• Do not rely on HbA1c to diagnose diabetes in under 18s.
• Do not order C-peptide or diabetes-specific autoantibodies at initial presentation to distinguish type 1 from type 2.

Treat / advise

• If suspected diabetes and clinically stable: arrange same day paediatric diabetes team referral.
• If emergency features: arrange emergency admission to acute paediatric facilities.
• If already diagnosed and unwell but not requiring admission: reinforce the specialist team’s sick-day plan and ensure the family has contact details.

Refer

• Same day paediatric diabetes team for suspected type 2 diabetes.
• Emergency paediatric admission for suspected diabetic ketoacidosis or hyperosmolar hyperglycaemic state.

Review / follow-up

• For known type 2 diabetes, ensure 3 monthly HbA1c review, annual complication screening, psychosocial support and transition planning are happening.
• Liaise with the paediatric diabetes team if uncertain.

9. Practical Use in GP: How to Apply This Topic

Before action

• Decide whether the child is acutely unwell. If diabetic ketoacidosis or hyperosmolar hyperglycaemic state is possible, this is an emergency admission problem.
• If diabetes is suspected but the child is stable, arrange same day paediatric diabetes team review.

What the GP can safely do

• Recognise possible diabetes.
• Check capillary glucose and blood ketones where indicated and available.
• Arrange same day referral or emergency admission.
• Reinforce paediatric diabetes team advice on diet, activity, monitoring, sick days, diabetes identification and attending screening.
• Support psychosocial assessment and referral.

What requires specialist leadership

• Confirmation of diabetes type.
• Starting antidiabetic drug treatment.
• Insulin initiation, titration and reduction.
• Liraglutide, dulaglutide or empagliflozin initiation.
• Continuous glucose monitoring device choice and training.
• Management of hypertension, dyslipidaemia or albuminuria once detected.

Sick-day practical points

• During intercurrent illness, follow the paediatric diabetes team’s sick-day plan.
• If the child or young person is taking metformin and is dehydrated, vomiting, has diarrhoea, fever or reduced fluid intake, metformin should be temporarily stopped and healthcare advice sought.
• If taking a sodium-glucose co-transporter 2 (SGLT-2) inhibitor and diabetic ketoacidosis is suspected, stop it and seek urgent medical advice; during acute serious illness, major surgery or volume depletion, interrupt treatment and follow specialist advice on ketone monitoring.
• Do not stop insulin.
• Insulin dose may need alteration during illness; seek specialist diabetes advice if uncertain.
• Blood ketones may need checking regularly, for example every 3–4 hours including overnight, depending on specialist advice.
• If blood ketones are greater than 3 mmol/L, seek immediate medical advice.
• Maintain normal meals, fluids and carbohydrate intake where possible.
• If unable to eat or vomiting, replace meals with carbohydrate-containing drinks.
• If blood glucose is high, maintain fluid intake with sugar-free fluids.
• If blood glucose is low, encourage sugary fluids.

What not to do

• Do not manage suspected paediatric type 2 diabetes as routine adult diabetes.
• Do not start adult type 2 diabetes drug sequences.
• Do not invent insulin dose changes, device instructions or local pathway details; use the local paediatric diabetes referral route.

10. Medicines, Investigations and Intervention Safety

Metformin

• Metformin is specialist-led in this age group.
• Role: standard-release metformin is offered from diagnosis as part of paediatric diabetes team-led care. NICE NG18 notes that formulations other than standard-release metformin were off-label in May 2023.
• Named medicine: metformin hydrochloride.
• Paediatric dosing is specialist-use information; the GP exam point is that treatment is specialist-led.
• Safety: check renal function before treatment and at least annually; more often if renal impairment risk or deterioration is suspected. Avoid if estimated glomerular filtration rate is below 30 mL/min/1.73 m².
• During intercurrent illness with dehydration, vomiting, diarrhoea, fever or reduced fluid intake, metformin should be temporarily stopped and healthcare advice sought.
• Adverse effects include gastrointestinal symptoms and vitamin B12 deficiency. Test vitamin B12 if deficiency is suspected, for example megaloblastic anaemia or new-onset neuropathy.

Insulin

• Used if HbA1c is 69 mmol/mol (8.5%) or more at diagnosis, or if targets are not achieved with metformin plus liraglutide, dulaglutide or empagliflozin.
• Basal-bolus insulin is offered if ketosis is present but not diabetic ketoacidosis.
• If insulin was started from diagnosis, it may be gradually reduced with the aim of stopping if target HbA1c or glucose ranges are achieved.
• Hypoglycaemia education, injection technique, glucose monitoring and injection-site review are required.
• Insulin titration decisions remain specialist-led.

Liraglutide and dulaglutide

• Medicine class: glucagon-like peptide-1 (GLP-1) receptor agonists.
• For children and young people aged 10 years or over with type 2 diabetes who are on metformin, the paediatric diabetes team should offer liraglutide or dulaglutide (depending on preference) if any of the following apply: HbA1c is more than 48 mmol/mol (6.5%). Fasting or pre-meal plasma glucose is more than 7 mmol/L on 4 or more days a week. 2 hour post-meal plasma glucose is more than 9 mmol/L on 4 or more days a week.
• Liraglutide route is subcutaneous injection; injection into abdomen, thigh or upper arm with site rotation.
• For GLP-1 receptor agonists, seek urgent medical assessment for persistent severe abdominal pain, especially if it radiates to the back or is associated with nausea or vomiting. Discontinue the GLP-1 receptor agonist if pancreatitis is suspected, and do not restart it if pancreatitis is confirmed.
• GLP-1 receptor agonists are not substitutes for insulin; any insulin dose reduction should be specialist-led, stepwise and accompanied by careful glucose monitoring.
• Dulaglutide initiation and dosing decisions remain specialist-led.

Empagliflozin

• Medicine class: sodium-glucose co-transporter 2 inhibitor.
• From age 10, empagliflozin may be considered if the escalation criteria are met and liraglutide or dulaglutide is not tolerated, or there is a clear preference for empagliflozin.
• BNF Children labels empagliflozin as unlicensed use in this context, so prescribing decisions should remain specialist-led.
• Safety: this class is associated with diabetic ketoacidosis, sometimes with normal or near-normal glucose. Stop and seek urgent medical advice if diabetic ketoacidosis is suspected. During acute serious illness, major surgery or volume depletion, interrupt treatment and follow specialist advice on ketone monitoring.
• Fournier’s gangrene is rare but potentially life-threatening.
• Empagliflozin initiation and dosing decisions remain specialist-led.

Continuous glucose monitoring

• Full term: continuous glucose monitoring.
• Real-time continuous glucose monitoring may be offered if the child cannot engage with capillary monitoring because of need, condition or disability, would otherwise need at least 8 daily checks, or has recurrent or severe hypoglycaemia.
• It may be considered for children and young people on insulin therapy.
• Intermittently scanned continuous glucose monitoring, commonly called flash, may be considered from age 4 if on insulin and real-time continuous glucose monitoring is contraindicated or there is a clear preference.
• Users still need capillary blood glucose checks for device accuracy and as back-up.

Complication screening

• HbA1c: every 3 months; target 48 mmol/mol (6.5%) or lower, individualised.
• Growth and weight: measure height and weight, calculate body mass index (BMI) and plot on an appropriate growth chart; significant growth or weight changes may reflect changes in blood glucose control.
• Albumin:creatinine ratio: annually from diagnosis; early morning urine preferred.
  • If ACR is above 3 but below 30 mg/mmol, repeat twice using early morning samples before further action.
  • If ACR is 30 mg/mmol or more, investigate further.
• Eye care: before age 12, children should have an eye examination by an optometrist every 2 years. Refer to the local diabetic eye screening programme before the twelfth birthday so screening starts from age 12. Consider ophthalmology retinal examination for children under 12 if blood glucose control is suboptimal.
• Blood pressure: screen annually from diagnosis using the correct cuff size. If repeated resting blood pressure measurements are above the 95th percentile for age, sex and height, confirm hypertension using 24 hour ambulatory blood pressure monitoring before further investigation and specialist treatment.
• Lipids: annually from diagnosis once glucose control is achieved; measure total cholesterol, high-density lipoprotein cholesterol, non-high-density lipoprotein cholesterol and triglycerides; confirm abnormal results with a repeat sample.
• Feet: under 12s need basic foot care advice; ages 12–17 need annual foot assessment by the paediatric or transitional care team. If a diabetic foot problem is found or suspected, arrange referral to an appropriate specialist.

11. How to Explain It to the Patient

“The symptoms you describe could be diabetes, and in children we need a specialist paediatric diabetes team to confirm the type safely.”

“Even when type 2 diabetes seems likely, we do not assume it in children, because type 1 diabetes can look similar at the start.”

“I am arranging same-day specialist review because treatment and monitoring need to start in the right team.”

“If you vomit, cannot drink, become very drowsy, breathe unusually fast, or ketones are high, this needs urgent medical help.”

“The aim is to keep glucose controlled while also supporting growth, school, mood, family life and avoiding complications.”

“Please keep the diabetes team contact details with you, and wear or carry diabetes identification.”

12. When the Plan Changes

• If the child or young person has vomiting, abdominal pain, dehydration, drowsiness, confusion or abnormal breathing
  • Why this changes the plan: diabetic ketoacidosis may be present, including in type 2 diabetes.
  • What the GP does now: check glucose and blood ketones if available and arrange emergency admission to acute paediatric facilities.
• If type 2 diabetes is suspected but the child is clinically stable
  • Why this changes the plan: diagnosis still needs same-day specialist confirmation.
  • What the GP does now: arrange immediate same-day multidisciplinary paediatric diabetes team referral.
• If HbA1c is 69 mmol/mol (8.5%) or more at diagnosis
  • Why this changes the plan: specialist management includes insulin in addition to metformin.
  • What the GP does now: ensure paediatric diabetes team-led care; do not independently start adult pathways.
• If ketosis is present but diabetic ketoacidosis is not present
  • Why this changes the plan: ketosis signals higher-risk diabetes at presentation; if ketosis is present but diabetic ketoacidosis is not present, basal-bolus insulin should be offered under paediatric diabetes team-led care.
  • What the GP does now: urgent paediatric diabetes team management; if diabetic ketoacidosis features develop, emergency admission.
• If glucose targets are not met after metformin in a child aged 10 or over
  • Why this changes the plan: liraglutide or dulaglutide should be offered in paediatric diabetes team-led care if the listed criteria are met; empagliflozin may be considered if those are not tolerated or there is a clear preference for empagliflozin.
  • What the GP does now: liaise with the paediatric diabetes team; do not invent doses or start unsupported medicines.
• If there is persistent difficulty with glucose control, mood symptoms, family conflict or suspected anxiety/depression
  • Why this changes the plan: psychosocial issues can affect wellbeing and diabetes management.
  • What the GP does now: involve diabetes-aware mental health support and the paediatric diabetes team.

13. Common AKT / SCA Traps

• Treating suspected diabetes in a child as routine adult type 2 diabetes.
• Forgetting to assume type 1 diabetes unless strong type 2 indicators exist.
• Using HbA1c to diagnose diabetes in under 18s.
• Measuring C-peptide or diabetes-specific autoantibodies at first presentation to distinguish type 1 from type 2.
• Missing diabetic ketoacidosis because the child has features of type 2 diabetes.
• Assuming normal or near-normal glucose excludes diabetic ketoacidosis in an insulin-treated young person or SGLT-2 inhibitor user.
• Starting adult drug algorithms, semaglutide, tirzepatide, pioglitazone or adult cardiovascular pathways in a paediatric topic.
• Giving paediatric empagliflozin or dulaglutide doses in a GP rather than keeping prescribing specialist-led.
• Forgetting the 4 week review after diagnosis and metformin initiation.
• Missing annual albumin:creatinine ratio, blood pressure and lipid monitoring from diagnosis.
• Forgetting growth, BMI and age specific eye and foot care.
• Forgetting retinopathy screening from age 12.
• Ignoring school plans, emotional health, eating disorders, family conflict, sexual health where appropriate, and transition.

14. Common Exam Angles

• Angle: Obese adolescent with thirst, tiredness and acanthosis nigricans.
  • Hidden challenge: type 2 diabetes is likely, but type 1 must not be dismissed.
  • What the candidate must not miss: same-day paediatric diabetes team referral.
• Angle: Known type 2 diabetes, vomiting and abdominal pain.
  • Hidden challenge: diabetic ketoacidosis can occur in type 2 diabetes.
  • What the candidate must not miss: blood ketones if available and emergency paediatric admission if suspected.
• Angle: Child aged 10 or over not controlled on metformin.
  • Hidden challenge: escalation is specialist-led and uses paediatric criteria.
  • What the candidate must not miss: liraglutide or dulaglutide should be offered if criteria are met; empagliflozin may be considered if those are not tolerated or there is a clear preference for empagliflozin.
• Angle: Young person struggling with adherence and school disruption.
  • Hidden challenge: psychosocial issues are part of diabetes management.
  • What the candidate must not miss: involve the paediatric diabetes team, update school planning where treatment changes affect school, and support mental health.

15. 90 Second Audio Summary Script

Type 2 diabetes in children and young people is not just adult diabetes at a younger age. For the MRCGP, the first rule is: in a child with suspected diabetes, assume type 1 unless there are strong indicators of type 2, such as obesity, strong family history, Black or Asian background, insulin resistance, not needing insulin, or needing less than 0.5 units per kilogram per day after the partial remission phase.

The GP’s safest action is same-day referral to the multidisciplinary paediatric diabetes team for confirmation and immediate care. Do not diagnose under 18s using HbA1c, and do not order C-peptide or diabetes autoantibodies at first presentation to separate type 1 from type 2.

Always screen the consultation for emergency features. Vomiting, abdominal pain, dehydration, drowsiness, confusion, shortness of breath, fruity breath or Kussmaul breathing should make you think about diabetic ketoacidosis. Type 2 diabetes can still develop diabetic ketoacidosis. Hyperosmolar hyperglycaemic state is also an emergency and is suggested by severe hyperglycaemia developing over days, marked dehydration or hypovolaemia, confusion or drowsiness, and no significant ketosis.

Management is paediatric diabetes team-led. Standard-release metformin is offered from diagnosis. Insulin is used if HbA1c is 69 mmol/mol or more, and basal-bolus insulin is used if there is ketosis but not diabetic ketoacidosis. From age 10, liraglutide or dulaglutide should be offered if criteria are met despite metformin; empagliflozin may be considered if those are not tolerated or there is a clear preference.

Sick-day advice must stay medicine safe: follow the paediatric diabetes team plan, do not stop insulin, stop metformin temporarily if dehydrated, vomiting, has diarrhoea, fever or reduced fluid intake, and stop an SGLT-2 inhibitor with urgent advice if diabetic ketoacidosis is suspected. GLP-1 receptor agonists need urgent assessment for persistent severe abdominal pain; stop if pancreatitis is suspected and do not restart if confirmed.

Monitoring is structured: HbA1c every 3 months, annual blood pressure, lipids and albumin:creatinine ratio from diagnosis, growth and BMI plotting, retinopathy screening from age 12, and age appropriate foot care. In the SCA, be practical and non-judgemental: explain same-day referral, check the sick-day plan, ask about school, mood and confidential sexual health where appropriate, and give clear urgent advice for vomiting, dehydration, high ketones, drowsiness or breathing difficulty.

References

• Association of Children’s Diabetes Clinicians and British Society for Paediatric Endocrinology and Diabetes (2017) Practical management of hyperglycaemic hyperosmolar state (HHS) in children. Version 2, July 2017. Available at: https://www.bsped.org.uk/media/1382/practical-management-of-hyperglycaemic-hyperosmolar-state-hhs-in-children-2.pdf (Accessed: 27 April 2026).
• British Society for Paediatric Endocrinology and Diabetes (2021) BSPED guideline for the management of children and young people under the age of 18 years with diabetic ketoacidosis. Available at: https://www.bsped.org.uk/media/v2ydcuv0/bsped-dka-guideline-v3.pdf (Accessed: 27 April 2026).
• Brown & Burk UK Ltd (2025) Metformin 500 mg film-coated tablets: Summary of Product Characteristics. electronic Medicines Compendium. Available at: https://www.medicines.org.uk/emc/product/10759/smpc (Accessed: 27 April 2026).
• Medicines and Healthcare products Regulatory Agency (2016) SGLT2 inhibitors: updated advice on the risk of diabetic ketoacidosis. Drug Safety Update, 18 April. Available at: https://www.gov.uk/drug-safety-update/sglt2-inhibitors-updated-advice-on-the-risk-of-diabetic-ketoacidosis (Accessed: 27 April 2026).
• Medicines and Healthcare products Regulatory Agency (2019a) SGLT2 inhibitors: reports of Fournier’s gangrene (necrotising fasciitis of the genitalia or perineum). Drug Safety Update, 18 February. Available at: https://www.gov.uk/drug-safety-update/sglt2-inhibitors-reports-of-fournier-s-gangrene-necrotising-fasciitis-of-the-genitalia-or-perineum (Accessed: 27 April 2026).
• Medicines and Healthcare products Regulatory Agency (2019b) GLP-1 receptor agonists: reports of diabetic ketoacidosis when concomitant insulin was rapidly reduced or discontinued. Drug Safety Update, 19 June. Available at: https://www.gov.uk/drug-safety-update/glp-1-receptor-agonists-reports-of-diabetic-ketoacidosis-when-concomitant-insulin-was-rapidly-reduced-or-discontinued (Accessed: 27 April 2026).
• Medicines and Healthcare products Regulatory Agency (2020) SGLT2 inhibitors: monitor ketones in blood during treatment interruption for surgical procedures or acute serious medical illness. Drug Safety Update, 18 March. Available at: https://www.gov.uk/drug-safety-update/sglt2-inhibitors-monitor-ketones-in-blood-during-treatment-interruption-for-surgical-procedures-or-acute-serious-medical-illness (Accessed: 27 April 2026).
• Medicines and Healthcare products Regulatory Agency (2022) Metformin and reduced vitamin B12 levels: new advice for monitoring patients at risk. Drug Safety Update, 20 June. Available at: https://www.gov.uk/drug-safety-update/metformin-and-reduced-vitamin-b12-levels-new-advice-for-monitoring-patients-at-risk (Accessed: 27 April 2026).
• Medicines and Healthcare products Regulatory Agency (2026) GLP-1 receptor agonists and dual GLP-1/GIP receptor agonists: strengthened warnings on acute pancreatitis, including necrotising and fatal cases. Drug Safety Update, 29 January. Available at: https://www.gov.uk/drug-safety-update/glp-1-receptor-agonists-and-dual-glp-1-slash-gip-receptor-agonists-strengthened-warnings-on-acute-pancreatitis-including-necrotising-and-fatal-cases (Accessed: 27 April 2026).
• National Institute for Health and Care Excellence (NICE) (2015a, updated 2019) Diabetic foot problems: prevention and management. NICE guideline NG19. London: NICE. Available at: https://www.nice.org.uk/guidance/ng19 (Accessed: 27 April 2026).
• National Institute for Health and Care Excellence (NICE) (2015b, updated 2020) Diabetes in pregnancy: management from preconception to the postnatal period. NICE guideline NG3. London: NICE. Available at: https://www.nice.org.uk/guidance/ng3 (Accessed: 27 April 2026).
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• NHS England (2026) Diabetic eye screening: programme overview. GOV.UK, last updated 17 March. Available at: https://www.gov.uk/guidance/diabetic-eye-screening-programme-overview (Accessed: 27 April 2026).
• Paediatric Formulary Committee (2025a) BNF for Children: Type 2 diabetes. London: BMJ Group, Pharmaceutical Press and RCPCH Publications. Available at: https://bnfc.nice.org.uk/treatment-summaries/type-2-diabetes/ (Accessed: 27 April 2026).
• Paediatric Formulary Committee (2025b) BNF for Children: Metformin hydrochloride. London: BMJ Group, Pharmaceutical Press and RCPCH Publications. Available at: https://bnfc.nice.org.uk/drugs/metformin-hydrochloride/ (Accessed: 27 April 2026).
• Paediatric Formulary Committee (2025c) BNF for Children: Dapagliflozin. London: BMJ Group, Pharmaceutical Press and RCPCH Publications. Available at: https://bnfc.nice.org.uk/drugs/dapagliflozin/ (Accessed: 27 April 2026).
• Paediatric Formulary Committee (2025d) BNF for Children: Liraglutide. London: BMJ Group, Pharmaceutical Press and RCPCH Publications. Available at: https://bnfc.nice.org.uk/drugs/liraglutide/ (Accessed: 27 April 2026).
• Paediatric Formulary Committee (2025e) BNF for Children: Diabetic hyperglycaemic emergencies. London: BMJ Group, Pharmaceutical Press and RCPCH Publications. Available at: https://bnfc.nice.org.uk/treatment-summaries/diabetic-hyperglycaemic-emergencies/ (Accessed: 27 April 2026).
• Royal College of General Practitioners (2025) Metabolic problems and endocrinology. RCGP curriculum topic guide. London: RCGP.
• Shah, A.S., Barrientos-Pérez, M., Chang, N., Fu, J.F., Hannon, T.S., Kelsey, M., Peña, A.S., Pinhas-Hamiel, O., Urakami, T., Wicklow, B., Wong, J. and Mahmud, F.H. (2024) ‘ISPAD Clinical Practice Consensus Guidelines 2024: Type 2 diabetes in children and adolescents’, Hormone Research in Paediatrics, 97(6), pp. 555–583. doi: 10.1159/000543033.

Important Disclaimer

This MedDigest MRCGP Topic Essentials is an independent educational and revision resource, created to support exam preparation only. It is not a clinical guideline, prescribing resource, or a substitute for your own professional judgment.

This content is designed to highlight exam-relevant clinical principles, management pathways, and consultation approaches in a concise format. Any example explanations, consultation wording, scenario angles, or summary scripts are illustrative and should not be used as stand-alone clinical advice.

This resource has not been produced, reviewed, or endorsed by NICE, the Royal College of General Practitioners, or any other official organisation.

Medicine and guidance change over time. For definitive recommendations, always consult the latest official guidance, the BNF, and your local clinical policies and referral pathways.

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