Early onset diabetes

For people diagnosed with early-onset diabetes (before the age of 4 years), the need for triple therapy with the addition of a GLP-1 receptor agonist (liraglutide, dulaglutide or semaglutide) or tirzepatide should be considered when initiating therapy due to the increased risk of morbidity and mortality.  

Dipeptidyl peptidase 4 (DPP-4) inhibitors, sulfonylureas, pioglitazone and insulin are options (depending on the circumstances) if treatment escalation is necessary. In the main, there are no significant changes to the recommendations for adding insulin and pioglitazone where people are not responding to other treatments and/or cannot tolerate other medicines.

Overall, monotherapy is not recommended unless it is unavoidable (e.g. to avoid risks from polypharmacy in people with multiple health conditions or in frailty). For example, metformin monotherapy may be appropriate in frail people where SGLT-2 inhibitors should be avoided due to adverse effects from risk of hypotension or volume depletion.

Monotherapy with DPP-4 inhibitors would be appropriate where metformin is contraindicated or not tolerated and SGLT-2 inhibitors cannot be used.