Multimorbidity - Diabetes, Hypertension and Hyperlipidaemia

Multimorbidity is commonly seen in primary care. Multimorbidity refers to the presence of several co-occurring long-term conditions, being related or not, in each patient¹. In the polyclinic setting, 50% of the patients had two chronic conditions in their early 50s, three chronic conditions in their early 60s and four chronic conditions in their late 70s². Multimorbidity is associated with higher healthcare cost in the primary care setting³. The commonest pattern of multimorbidity seen in primary care is the combination of the three chronic conditions – diabetes, hypertension and hyperlipidaemia⁴.

Clinical Approach

Minimally disruptive medicine (MDM)⁵ can be a framework to use for managing patients with multimorbidity. The aim is to reduce treatment burden and increase patient capacity .
Combining the individual treatment targets would be based on shared decision-making.

Management

Aims of management:

Prevent cardiovascular disease (CVD)
Prevent or delay progression of Target Organ Damage

Principles of Management

Screen for 10-year risk of Coronary Artery Disease .
Aim for disease management targets based on multimorbidity and macrovascular (other organ) complications (refer to Table 1).
Medication management for those with polypharmacy or transition of care⁷.

Table 1: Type 2 Diabetes Mellitus co-occurring with other organ complications

	Diabetes⁸ & Hypertension & Hyperlipidaemia⁹	Atherosclerosis/ Cardiovascular Disease⁶	Chronic Kidney Disease	Stroke⁶
Lifestyle	↓Weight ↑Exercise ↓Sedentary behaviour ↓Alcohol ↓Sodium Healthy Plate, DASH diet, ↓fat, avoid sugary drinks & food. ↓Stress Smoking cessation Manage sleep apnoea	Medical clearance may be recommended for exercise Assess fitness to drive annually	Medical clearance may be recommended for exercise Low protein diet (Limit to 2 servings of protein daily or < 0.8g/kg/day) For later CKD stages, ↓potassium, ↓phosphate & fluid restriction	Medical clearance may be recommended for exercise Assess fitness to drive annually
BP	< 140/80 mmHg		< 130/80 mmHg
LDL	LDL-cholesterol < 2.6 mmol/L or <100mg/dL	LDL-cholesterol < 2.1 mmol/L or <80mg/dL
HbA1c	General HbA1c target of ≤ 7.0%, but target of treatment should be personalised (e.g. for elderly)
Medication adjustment	Avoid diuretics Avoid β-blockers ACEI or ARB are preferred for BP control or albuminuria Fenofibrate for raised TG Metformin, SGLT2-inhibitor preferred for obese patients Whilst statins are generally the preferred choice for lipid disorders, the addition of fenofibrate to a statin may benefit certain patients with T2DM with both high TG and low HDL-cholesterol dyslipidaemia pattern, particularly those with microvascular complications⁹	ACEI or ARB preferred Consider to start and continue β-blockers indefinitely Beware of postural hypotension from HT and BP-lowering CVD drugs (e.g., ISDN) Start anti-platelets (Beware of low Hb with anti-platelets)	Maximise ACEI or ARB dosage Titrate hypoglycaemics as patients more susceptible to hypoglycaemia Use metformin, diuretics & fenofibrate with caution Fibrates can be used in patients in stage 1 to 3 CKD but the dosages should be reduced, with appropriate monitoring for side effects, especially myopathy. Fibrates are contraindicated for stage 4 or 5 CKD⁹.	Beware of postural hypotension from HT and BP-lowering CVD drugs e.g. ISDN Beware of low Hb with anti-platelets Antithrombotic therapy, including antiplatelet or anticoagulant agents, is recommended for nearly all patients without contra-indications High dose statin +/- ezetimibe
Others			For stage 3-5 CKD, consider checking calcium, phosphate, vitamin D, Hb and Ferritin levels

ACEI – Angiotensin converting enzyme inhibitors; ARB – Angiotensin receptor blockers; BP – Blood pressure; CVD – Cardiovascular disease; CKD – Chronic kidney disease; DASH - Dietary Approaches to Stop Hypertension; Hb- Haemoglobin; HbA1c – Glycated haemoglobin; HDL-cholesterol – High-density lipoprotein cholesterol; HT – Hypertension; ISDN - Isosorbide dinitrate; LDL-cholesterol – Low-density lipoprotein cholesterol; PARP – Physical activity recommendation process; SGLT2 – Sodium-glucose cotransporter-2 Inhibitors; T2DM – Type 2 Diabetes Mellitus; TG - Triglyceride

Data Submission (Refer to Diabetes, Lipid Disorder and Hypertension Care Protocols)

Financing (Refer to Diabetes, Lipid Disorder and Hypertension Care Protocols)

References

Mercer S, Salisbury C, Fortin M. ABC of Multimorbidity. BMJ Books. 2014.
Lee ES, Lee PSS, Xie Y, Ryan BL, Fortin M, Stewart M. The prevalence of multimorbidity in primary care: a comparison of two definitions of multimorbidity with two different lists of chronic conditions in Singapore. BMC Public Health. 2021;21(1).
Tan SY, Lew KJ, Xie Y, Lee PSS, Koh HL, Ding YY, et al. Healthcare cost of patients with multiple chronic diseases in Singapore public primary care setting. Annals of the Academy of Medicine, Singapore. 2021;50(11):809-17.
Tan SY, Lew KJ, Xie Y, et al. Healthcare cost of patients with multiple chronic diseases in Singapore public primary care setting. Annals of the Academy of Medicine, Singapore 2021;50(11):809-17. doi: 10.47102/annals-acadmedsg.2021246
Abu Dabrh AM, Gallacher K, Boehmer KR, et al. Minimally disruptive medicine: the evidence and conceptual progress supporting a new era of healthcare. J R Coll Physicians Edinb 2015;45(2):114-7. doi: 10.4997/JRCPE.2015.205
Kleindorfer DO, Towfighi A, Chaturvedi S, et al. 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association. Stroke 2021;52(7):e364-e467. doi: 10.1161/STR.0000000000000375 [published Online First: 2021/05/25]
Penm J, Vaillancourt R, Pouliot A. Defining and identifying concepts of medication reconciliation: An international pharmacy perspective. Res Social Adm Pharm. 2019 Jun;15(6):632-640. doi:10.1016/j.sapharm.2018.07.020. Epub 2018 Aug 1. PMID: 30100200.
Health Promotion Board. National. Diabetes Reference Materials. (Cited 27 May 2022)
MOH Clinical Practice Guidelines – Lipids 2016. (Cited 27 May 2022)
ACE Clinical Guidance. Chronic Kidney Disease – Early Detection [Internet]. 2022 [cited 2022 September 10].