Multimorbidity - Diabetes, Hypertension and Hyperlipidaemia
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​Last updated on 8 March 2024

  • Updated to align BP and LDL-cholesterol targets with the Hypertension and Lipids ACGs released on 15 Dec 2023.
  • Updated to align antihypertensive, lipid lowering, and oral antidiabetic pharmacological management approaches with the Hypertension and Lipid ACGs released on 15 Dec 2023, and Diabetes ACG released on 17 May 2023.
  • Updated 10-year coronary artery disease risk tables with the SG-FRS-2023 coronary artery disease risk model.
  • Updated Healthier SG CV Risk Calculator to align with Hypertension and Lipids ACGs released on 15 Dec 2023, and the SG-FRS-2023 coronary artery disease risk model.


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


  1. 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 .

  2. Combining the individual treatment targets would be based on shared decision-making.


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

  2. 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​

​​​​
​​​
​​

​Hyp​ertension & Hyperlipidae​mia8, 9, 10

​Atheroscle​rosis/ 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 

  • 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. ​

  • 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.

  • Moderate intensity statin +/- ezetimibe is appropriate 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 ​

  1. ​Mercer S, Salisbury C, Fortin M. ABC of Multimorbidity.  BMJ Books. 2014.

  2. 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).

  3. 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.

  4. 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 

  5. 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

  6. 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]

  7. 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.

  8. HealthHub. 3 Be’s to Beat Diabetes | Diabetes Hub. Singapore: Synapxe; 2023 [cited 2023 December 20].​ ​

  9. Agency for Care Effectiveness (ACE). Lipid management: focus on cardiovascular risk. ACE Clinical Guidance (ACG), Ministry of Health, Singapore. 2023.​

  10. Agency for Care Effectiveness (ACE). Hypertension – tailoring the management plan to optimise blood pressure control. ACE Clinical Guidance (ACG), Ministry of Health, Singapore. 2023.​ ​​

  11. ACE Clinical Guidance. Chronic Kidney Disease – Early Detection [Internet]. 2022 [cited 2022 September 10]. ​