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 patient.¹ 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 70s.² Multimorbidity is associated with higher healthcare cost in the primary care setting.³ The commonest pattern of multimorbidity seen in primary care is the combination of the three chronic conditions – diabetes, hypertension and hyperlipidaemia.⁴

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

Aim: Prevent or delay progression of cardiovascular disease (CVD) and other end-organ damage.
Principles of Management

Assess the patient’s cardiovascular risk using the cardiovascular disease (CVD) risk calculator . Alternatively, refer to Table 1 below for the appropriate BP and LDL-cholesterol targets.
Medication reconciliation for those with polypharmacy or transition of care.⁷

Table 1: Type 2 diabetes mellitus (T2DM) co-occurring with other organ complications

	Hypertension & Hyperlipidaemia^{8, 9, 10}	Atherosclerosis/ Cardiovascular Disease⁶	Chronic Kidney Disease¹¹	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 Consider 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 Targets (clinic reading)¹⁰	<130/80 mmHg
LDL-cholesterol⁹	Always individualise treatment Consider risk enhancers for CVD, potential benefits, tolerability of side effects of pharmaceutical therapies, life expectancy, and patient’s preferences.
LDL-cholesterol⁹	Aim <2.6 mmol/L or <100mg/dL Consider <1.8 mmol/L or <70 mg/dL (complicated or treatment resistant DM#)	Aim <1.8 mmol/L or 70 mg/dL (ASCVD e.g., Stable IHD, ischaemic stroke, TIA, PAD, AAA, post-CABG, post-PCI) Aim <1.4 mmol/L or <55 mg/dL (ASCVD – history of ACS e.g., MI, unstable angina)	Consider <1.8 mmol/L or <70 mg/dL	Aim <1.8 mmol/L or <70 mg/dL
HbA1c	General HbA1c target of ≤7.0%, but target of treatment should be personalised (e.g., ≤8.0% for elderly or ≤6.5% for younger patients with early-stage microvascular complications)
Medication adjustment/ reconciliation	For obese patients, consider metformin (neutral effect on weight) and SGLT2-I or GLP-1 RA (weight reduction effects). ACE-I/ARB recommended in patients with DM and DM with complications. Avoid beta blocker monotherapy unless patient requires heart rate reduction or has cardiac comorbidities like stable IHD or AF. Avoid thiazide/thiazide-like diuretics if patient is at risk for insulin resistance. Watch out for postural hypotension in patients with hypertension and IHD from antihypertensives and nitrates. Maximally tolerated statin +/- ezetimibe is indicated in patients with atherosclerotic cardiovascular disease including stroke and PAD, and complicated or treatment-resistant DM. Treat with at least a moderate intensity statin in uncomplicated DM.	Consider adding on T2DM medication with cardiorenal protective effects like SGLT2-I or GLP-1 RA. Avoid thiazide/thiazide-like diuretics if patient is at risk for insulin resistance. Watch out for postural hypotension in patients with hypertension and IHD from antihypertensives and nitrates. Maximally tolerated statin +/- ezetimibe is indicated in patients with atherosclerotic cardiovascular disease including stroke and PAD, and complicated or treatment-resistant DM.	Consider adding on T2DM medication with cardiorenal protective effects like SGLT2-I or GLP-1 RA. Adjust T2DM medication doses to avoid hypoglycaemia in patients with CKD. ACE-I/ARB recommended in patients with chronic kidney disease, and/or proteinuria. Maximally-tolerate ACE-I/ARB doses should be used in CKD patients. Avoid beta blocker monotherapy unless patient requires heart rate reduction or has cardiac comorbidities like stable IHD or AF. Avoid thiazide/thiazide-like diuretics if patient is at risk for insulin resistance. Watch out for postural hypotension in patients with hypertension and IHD from antihypertensives and nitrates. Maximally tolerated statin +/- ezetimibe is indicated in patients with atherosclerotic cardiovascular disease including stroke and PAD, and complicated or treatment-resistant DM. Adjust fibrate doses in CKD stage 1-3 and monitor for myopathy. Avoid fibrates in CKD stage 4-5.	Avoid beta blocker monotherapy unless patient requires heart rate reduction or has cardiac comorbidities like stable IHD or AF. Avoid thiazide/thiazide-like diuretics if patient is at risk for insulin resistance. Watch out for postural hypotension in patients with hypertension and IHD from antihypertensives and nitrates. Maximally tolerated statin +/- ezetimibe is indicated in patients with atherosclerotic cardiovascular disease including stroke and PAD, and complicated or treatment-resistant DM.

#: Complicated or treatment-resistant DM: comorbid CKD, multiple microvascular complications (retinopathy, neuropathy, nephropathy), DM disease duration 10 years or more, or glycaemic levels persistently above treatment targets despite optimal treatment.

Abbreviations: ACE-I – Angiotensin-converting enzyme inhibitors; ACS – Acute Coronary Syndrome; AF – Atrial Fibrillation; ARB – Angiotensin receptor blockers; BP – Blood pressure; CVD – Cardiovascular disease; CKD – Chronic kidney disease; DASH - Dietary Approaches to Stop Hypertension; GLP1-RA – Glucagon-like Peptide 1 Receptor Agonist; HbA1c – Glycated haemoglobin; HDL-cholesterol – High-density lipoprotein cholesterol; HTN – Hypertension; IHD – Ischaemic Heart Disease; LDL-cholesterol – Low-density lipoprotein cholesterol; PAD – Peripheral Arterial Disease; PARP – Physical activity recommendation process; SGLT2-I – 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

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