General practitioner role in transition of adolescents to adult diabetes management

All patients with type 1 diabetes and patients with type 2 diabetes aged younger than 25 years should be referred to a specialist diabetes service.

The general practitioner (GP) is a critical partner with the specialist service in the management of adolescents and young adults with diabetes. Ideally, the GP should be well engaged with the adolescent or young adult before transition occurs. The specialist diabetes service should communicate with the GP about the adolescent’s or young adult’s progress and treatment.

If the GP is aware that the adolescent or young adult has not been attending follow-up appointments with the adult specialist diabetes service, they should encourage re-engagement, particularly if the adolescent or young adult:

  • has abnormal findings following screening for complications
  • has a persistently elevated glycated haemoglobin (HbA1c) (eg more than 75 mmol/mol [9%])
  • is admitted to hospital for severe hypoglycaemia or diabetic ketoacidosis
  • has multiple comorbidities
  • is pregnant or is considering pregnancy.
If a specialist diabetes service for adults is not easily accessible, the GP may need to provide ongoing diabetes management after an adolescent or young adult leaves a child-centred specialist diabetes service. In this case, the GP should regularly screen for complications and monitor HbA1c; for recommended frequency of screening for and monitoring of chronic complications and conditions associated with type 1 diabetes, see Recommended frequency of screening for and monitoring of chronic complications and conditions associated with type 1 diabetes and type 2 diabetes, see Recommended frequency of screening for and monitoring of chronic complications and conditions associated with type 2 diabetes.

Liaison with an endocrinologist or a multidisciplinary diabetes team at a regional centre should be encouraged to optimise the adolescent’s or young adult’s management. This could include videoconferencing or other multimedia contact between the GP, the adolescent and the expert.