Diabetes Mellitus
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​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.)


  1. Optimise glycaemia control (Individualised HbA1c and treatment regimen).

  2. Avoid hyper and hypoglycaemic events.

  3. Weight management.

  4. Cardiovascular risk factor management

  5. Cardiorenal protection.

  6. Screen, prevent & minimise Target Organ Damage (macro & micro vascular complications).


1. ​​​Targets of DM Management
​
​Cli​nical Para​meter
 ​Tar​get
 ​Remarks
​HbA1c​
 ​≤ 7.0%​
 ​May be more or less stringent, depending on context and patient profile  (e.g. target HbA1c ≤ 6.5% for younger individuals, target HbA1c ​≤ 8% for older, frail individuals, or those with advanced microvascular and macrovascular complications.)

HbA1c may not be accurate in certain conditions .​
​LDL
 ​< 2.6 mmol/L (100mg/ dL)
 ​May be lower in presence of other comorbidities.
​BP
 ​< 140/80 mmHg
 ​May be lower in presence of other comorbidities​.
​BMI
 ​< 23 kg/m2​
 ​Or 5-10% body weight loss from diagnosis
​Pre-meal glucose
 ​4.0 - 7.0 mmol/L (72 - 126 mg/dL)
 ​6.5 - 9.0 mmol/L (118 - 162 mg/dL if frail or susceptible to hypoglycaemia)
2-hour​
Post-meal glucose
 ​5.0 - 10.0 mmol/L (90-180 mg/dL)
 ​​<12.0 mmol/L (216 mg/dL if frail or susceptible to hypoglycaemia)

  1. May consider regular blood glucose monitoring.

  2. Strongly consider diabetes education and support.

  3. Also see recommended care components  and frequency of tests.

  4. 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.​


2. Lifestyle

  1. Healthy Plate, ↓fat intake, avoid sugary drinks and food, ↓alcohol intake, stop smoking

  2. ↑physical activity, ↓​sedentary behaviour

  3. 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. ​​


3. Patient Empowerment

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:

  1. Adopting a biopsychosocial model in health planning

  2. Using Open questions, Affirmations, Reflections and Summaries (OARS)

  3. Using Teach-back technique which confirms understanding in a non-judgemental way

  4. 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. Medication​1,3,4
(Based on the Appropriate Care Guide on Oral Glucose-Lowering Agents in Type 2 Diabetes Mellitus, 3 August 2017)​

  1. ​Metformin as 1st line agent.

  2. Sulfonylureas, SGLT-2 Inhibitor or insulin as alternative or 2nd line  .

  3. Others :DPP-4 inhibitors, Meglitinides, Thiazolidinediones, α-glucosidase inhibitors & GLP-1 analogues.

  4. ​Insulin initiation in patients with severe hyperglycemia or glycaemic targets are not met on oral glucose-lowering agents.​​


5. Behaviour

    GPs should educate their patients on:

  1. Symptoms of hypoglycaemia and hyperglycaemia, 

  2. Self blood glucose monitoring (SBGM)  ,

  3. Insulin injection, 

  4. Good foot care practices​​5,6,

  5. Special circumstances like acute Illness ​, dental care​, follow-up for women with a history of gestational di​abetes mellitus post-pregnancy , Ramadan  and travel across time zones ​.


6. Vaccination5 - Influenza and Pneumococcal.

Please refer to the Adult Vaccination Care Protocol​ for further details on vaccinations for diabetes patients.​


7. Regular Assessment

  1. ​Regular assessments for control of disease . GPs may refer to the Diabetes Patient Dashboard on NEHR to assist with regular monitoring .

  2. Referral pathways for patients with diabetic eye conditions​.

  3. Referral pathways for patients with diabetic foot conditions.

  4. Podiatary referral criteria ​ .

  5. 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​

  1. 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.

  2. 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.

  3. 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

  1. HbA1c (%)*
  2. Date *


Lipid profile

  1. LDL-Cholesterol (mmol/L or mg/dL) * 
  2. HDL-Cholesterol (mmol/L or mg/dL) 
  3. Triglycerides (mmol/L or mg/dL) 
  4. Total Cholesterol (mmol/L or mg/dL) 
  5. Date * 

Blood Pressure

  1. Systolic BP (mmHg)*
  2. Diastolic BP (mmHg)*
  3. Date *


Weight

  1. BMI (kg/m2), calculated from height*, weight*
  2. Waist Circumference (in cm; optional field to fill)
  3. Date *


Kidney assessment

  1. Serum creatinine (mol/L)* OR eGFR (ml/min/1.73m2)*
  2. Urine ACR (mg/mmol)*  OR Urine PCR (mg/mmol)*
  3. Date *

Diabetic Retinal Photography

  1. Conducted?*
    • Yes
    • No
    • NA: patient on active follow up with ophthalmologist#
  2. Date *#
  3. Results*
    • No abnormality detected
    • Non-proliferative retinopathy
    • Proliferative retinopathy
    • Diabetic maculopathy
    • Other abnormalities (e.g. cataract, ungradable)
    • Result unknown#
  4. Follow up actions
  5. Other findings
  6. Detailed report & image

# 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

  1. Conducted? *:
    • Yes
    • No#
    • NA: patient on active follow up with orthopaedics, vascular surgery or podiatry #
  2. Date of visit*#
  3. Outcome*# (refer to ACG 2019 DFS guideline)
    • Low risk for diabetic foot ulcers
    • Moderate risk for diabetic foot ulcers
    • High Risk for diabetic foot ulcers
    • Result unknown#

# Notes:

  • 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

  1. Influenza Vaccination* (Yes/No), Date of Vaccination*
  2. Pneumococcal Vaccination* (Yes/No), Date of Vaccination*


Smoking History

  1. Smoking Status*:
    • Never smoker
    • Ex-smoker
    • Current smoker
  2. Year Started Smoking (if smoker)
  3. No. of sticks smoked/day* (if smoker)
  4. Stage of change: (i) Pre-contemplation, (ii) Contemplation, (iii) Preparation (iv) Action, or (v) Maintenance


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. ​