GP Helpline:
Last updated on 21 April 2023
This Care Protocol is focused on patients diagnosed with Type 2 Diabetes Mellitus.
Prevalence of Diabetes Mellitus in the National Population Health Survey 2020 was 9.5%1. Chronic hyperglycaemia is associated with long-term sequelae resulting from damage to various organs and tissues, particularly the kidney, eye, nerves, heart and blood vessels. There are several ways to screen and diagnose . (Refer to Pre-DM care protocol if Pre-DM is diagnosed2.)
Optimise glycaemia control (Individualised HbA1c and treatment regimen).
Avoid hyper and hypoglycaemic events.
Weight management.
Cardiovascular risk factor management
Cardiorenal protection.
Screen, prevent & minimise Target Organ Damage (macro & micro vascular complications).
May consider regular blood glucose monitoring.
Strongly consider diabetes education and support.
Also see recommended care components and frequency of tests.
For patients with co-morbidities, the CVD risk calculator may be used to determine their 10-year Coronary Artery Disease (CAD) risk and their lipid, BP and HbA1c targets.
Healthy Plate, ↓fat intake, avoid sugary drinks and food, ↓alcohol intake, stop smoking
↑physical activity, ↓sedentary behaviour
Stress management - screen for depression (PHQ2)
GPs may tap on their Primary Care Network (PCN) teams for lifestyle counselling-related support.
Please refer to the National Diabetes Reference Materials (NDRM) on HealthHub which provides consistent information in lay language across settings. It is a resource for patients, caregivers and care teams to help in the understanding of Diabetes Mellitus and motivates patients for sustained lifestyle changes. You may download the materials (available in four languages) for patient education.
Empowering patients to own their treatment goals is important to achieving sustained lifestyle changes and health improvement. Through person-centred communication and engagement, GPs can raise their patients’ health literacy, so that patients co-own their care journeys. The key aspects of patient empowerment framework which are common across healthcare institutions include:
Adopting a biopsychosocial model in health planning
Using Open questions, Affirmations, Reflections and Summaries (OARS)
Using Teach-back technique which confirms understanding in a non-judgemental way
Setting SMART goals (Specific, Measurable, Action-oriented, Realistic, Time-limited)
For more details, please refer to [placeholder] for the playbook on Care Team Education for Person-Centred Communication. 4. Medication1,3,4(Based on the Appropriate Care Guide on Oral Glucose-Lowering Agents in Type 2 Diabetes Mellitus, 3 August 2017)
Metformin as 1st line agent.
Sulfonylureas, SGLT-2 Inhibitor or insulin as alternative or 2nd line .
Others :DPP-4 inhibitors, Meglitinides, Thiazolidinediones, α-glucosidase inhibitors & GLP-1 analogues.
Insulin initiation in patients with severe hyperglycemia or glycaemic targets are not met on oral glucose-lowering agents.
Symptoms of hypoglycaemia and hyperglycaemia,
Self blood glucose monitoring (SBGM) ,
Insulin injection,
Good foot care practices5,6,
Special circumstances like acute Illness , dental care, follow-up for women with a history of gestational diabetes mellitus post-pregnancy , Ramadan and travel across time zones .
Regular assessments for control of disease . GPs may refer to the Diabetes Patient Dashboard on NEHR to assist with regular monitoring .
Referral pathways for patients with diabetic eye conditions.
Referral pathways for patients with diabetic foot conditions.
Podiatary referral criteria .
Diabetic foot fast track criteria for Emergency Department and specialist outpatient clinic (SOC) referrals.
8. Screen and Co-Manage other Co-morbidities
9. Special Considerations - Type 1 Diabetes Mellitus
Such patients are often co-managed with specialists. Hence, offer patients with possible or definite Type 1 DM a referral to a specialist to make a recommendation on the therapy regimen.
Seek guidance from the primary Endocrinologist of the patient for the individualised medications for clinical management. All patients with Type 1 DM must receive insulin. Multiple daily injections (3 or more), or the use of continuous subcutaneous insulin infusion may be required to achieve target glucose levels.
Patients with Type 1 DM should have thyroid function checked every 1-2 years, beyond the regular assessments recommended for patients with Type 2 DM.
The following data fields should also be documented in GPs' case notes as part of good clinical practice for all patients enrolled to their practice.
Submission of data fields marked with asterisks* is required for subsidy claims and Healthier SG payments.
DM Control
Lipid profile
Blood Pressure
Weight
Kidney assessment
Diabetic Retinal Photography
# Notes:
If the patient has no perception to light for both eyes, select “No" for “DRP Conducted" as they do not require DRP. GP should note down in the clinical notes that patient has no perception to light for both eyes and does not require DFS.
If "NA" is selected under "DRP Conducted", GP will be eligible for variable component payment provided date of visit and results are submitted.]
For "Date of Visit", fill date of last diabetic retinal photography or eye assessment at the SOC.
For "Outcome", select "Result Unknown" if GP is unable to obtain DRP/eye assessment results. This does not include ungradable DRP results (GP should select 'other abnormalities' for ungradable DRPs). GP will not be eligible for payment if this is selected as decisions on further clinical care may not be conclusive.
Diabetic Foot Screening
If the patient has bilateral lower limb amputations, select "No" for "DFS Conducted" as they do not require DFS. GP should note down in clinical notes that patient is a bilateral amputee and does not require DFS.
If the patient is on specialist management for foot-related issues and does not require DFS, select "NA" for "DFS Conducted". GPs will be eligible for variable component payment provided date of visit and outcomes are provided.
For "Date of Visit", fill date of last DFS or foot assessment by podiatry or SOC.
For "Outcome", if both feet have different risk outcomes, the higher risk tier should be selected
For "Outcome", select "Result Unknown" if GP is unable to obtain results of foot screening performed elsewhere. GP will not be eligible for payment this is selected as decisions on further clinical care may not be conclusive.
Vaccination
Smoking History
CHAS/PG/MG cardholders who are Healthier SG enrolees will be eligible for the Healthier SG Chronic Tier, which provides percentage-based subsidies for a whitelist of drug products sold within the MOH price caps at capped selling price . When making claims, GPs will need to submit the quantities and selling prices for each whitelisted drug product prescribed.
Details on the GP annual service fee for enrolees with DM can be found in the Healthier SG Enrolment Programme Agreement.
HealthHub. Diabetes Hub: Guide to Managing Diabetes.
MOH. National Population Health Survey 2020 [Internet]. 2020 [cited 2022 August 17]
ACG. Managing pre-diabetes - a growing health concern [Internet]. 2021 [cited 2022 August 17]
ACG. Oral glucose-lowering agents in type 2 diabetes mellitus – an update [Internet]. 2017 [cited 2022 August 17]
ACG. Initiating basal insulin in type 2 diabetes mellitus [Internet]. 2022 [cited 2022 August 17]
MOH. Disease Specific Guidelines - Diabetes Mellitus and Pre-diabetes. Chronic Disease Management Programme - Handbook for Healthcare Professionals,2022