Last updated on 31 July 2023
This Care Protocol is focused on patients diagnosed with Type 2 Diabetes Mellitus.
Prevalence of diabetes mellitus (DM) 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 DM
(Refer to pre-DM care protocol if pre-DM is diagnosed.2)
Assess glycaemic control and risk of adverse cardiorenal outcomes.
Optimise glycaemia control (Individualised HbA1c targets) and avoid hyper and hypoglycaemic events.
Consider using cardiorenal protective medications, such as SGLT2 inhibitors and GLP1 receptor agonists.
Control cardiovascular risk factors, including encouraging weight reduction.
Screen for micro and macrovascular complications regularly.
Engage in patient education and shared decision-making.
May consider regular self blood glucose monitoring. 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, blood pressure (BP) and HbA1c targets.
Healthy Plate, ↓fat intake, avoid sugary drinks and food,
↓alcohol intake, stop smoking.
Stress management - screen for depression (PHQ2).
GPs may tap on their Primary Care Network (PCN) teams for lifestyle counselling-related support.
GPs may 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 DM and motivates patients for sustained lifestyle changes. GPs may download the materials (available in four languages) for patient education.
Care teams may use the relevant Lifestyle Prescription to help patients understand practical steps they can take to manage diabetes mellitus. A copy may be printed for the patient's use.
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 the
MOH playbook on Care Team Education for Person-Centred Communication.
4. Medication1,3,4(Adapted from the ACE Clinical Guidance on Type 2 Diabetes Mellitus: personalising management with non-insulin medications: 17 May 2023)
Consider Metformin as 1st line agent.
Other glucose-lowering agents such as sulfonylureas and DPP-4 inhibitors may be considered as add-on therapy when glycaemic control is the priority. If cost is a consideration and there are no concerns about hypoglycaemia or weight gain, sulfonylureas can be considered.
Consider adding on
SGLT-2 Inhibitors or GLP-1 Receptor Agonists for patients requiring cardiorenal risk reduction, irrespective of their need for improved glycaemic control.
Consider initiating dual therapy in patients in whom initial Hba1c is ≥1.5% above target, or those in whom monotherapy is not expected to be sufficient. This should be weighed against the cost and ability to more easily monitor the beneficial and adverse effects of new medications that started sequentially.
Consider insulin initiation in patients with severe hyperglycemia or failure to meet glycaemic targets despite optimal treatment with other glucose-lowering agents.
Please refer to Healthier SG whitelist for a full list of subsidised drugs (early access 2024)
Symptoms of hypoglycaemia and hyperglycaemia,
Self blood glucose monitoring (SBGM) ,
foot care practices,5,6 and
Special circumstances like acute Illness
dental care, follow up for women with a history of gestational diabetes mellitus (GDM) 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
. For more information on DRP screening, please refer to the
DRP Screening Technical Reference Guide.
Referral pathways for patients with diabetic eye conditions.
Referral pathways for patients with diabetic foot conditions:
8. Screen and Co-Manage other Comorbidities
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 (T1DM) 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 T1DM 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 T1DM should have their thyroid function checked every 1-2 years.
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.
Diabetic Retinal Photography (DRP)
If "NA: patient on active follow up with ophthalmologist" is selcted under "DRP Conducted", GPs will be eligible for variable component payment of the diabetes bundle provided date of visit and results are submitted.
If "NA: patient has no perception of light in both eyes (complete blindness)" is selected under “DRP Conducted", GPs may be eligible for partial payment of the variable component of the diabetes bundle. Note that the IT enhancement on the CMS systems is in progress andGPs may enter such indications once ready.
For "Date of Visit", fill date of last DRP or eye assessment at the SOC.
For "Outcome", select "Unknown" if GPs are unable to obtain DRP/eye assessment results. GPs will not be eligible for payment if this is selected as decisions on further clinical care may not be conclusive.
Diabetic Foot Screening (DFS)
If the patient is on specialist management for foot-related issues and does not require DFS, select "NA: patient on active follow up with orthopaedics, vascular surgery or podiatry" for "DFS conducted". GPs will be eligible for the variable component payment for the diabetes bundle as long as date of visit and outcomes are provided.
If "NA: patient has bilateral lower limb amputation above ankle joint" is selected under "DFS Conducted", GPs may be eligible for partial payment of the variable component of the diabetes bundle. Note that IT enhancements for the CMS systems is in progress and GPs may enter such indications once these are ready.
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 "Unknown" if GP is unable to obtain results of foot screening performed elsewhere. GPs will not be eligible for payment if this is selected as decisions on further clinical care may not be conclusive.
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. 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
ACG. Type 2 diabetes mellitus – personalising management with non-insulin medications [internet]. 2023 May 17 [cited 2023 July 5].