Diabetes Mellitus
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​Last updated on 23 Jan 2025

  • Alignment to 2024 ACG on 'initiating basal insulin in type 2 diabetes mellitus' under Management section - Medication

  • Updated references to align with 2024 ACG on 'foot assessment in people with diabetes mellitus'


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 8.5%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 for and diagnose DM . (Refer to pre-DM care protocol if pre-DM is diagnosed.2)


  1. Assess glycaemic control and risk of adverse cardiorenal outcomes.

  2. Optimise glycaemia control (Individualised HbA1c ​targets) and avoid hyper and hypoglycaemic events.

  3. Consider use of cardiorenal protective medications, such as SGLT2 inhibitors and GLP1 receptor agonists.

  4. Control cardiovascular risk factors, including encouraging weight reduction.

  5. Engage in patient education and adopt a patient-centred approach to make shared decisions on T2DM management.

  6. Review all patients with T2DM regularly, including treatment response and screening for micro and macrovascular complication screening. 


1. ​​​Targets of DM Management
​
​Cli​nical Para​meter
 ​Tar​get
 ​Remarks
​HbA1c​
 ​≤7.0%​
 Individualised HbA1c targets ​

HbA1c may not be accurate in certain conditions .
​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)
​LDL-cholesterol
 ​<2.6 mmol/L (100 mg/ dL)

​May be lower in presence of:

a. Other comorbidities, or

b. Concurrent CKD, or

c. Two or more microvascular complications (retinopathy, neuropathy, nephropathy), or

d. DM duration ≥10 years, or

e. Persistently elevated glycaemic levels despite optimised treatment​

​Blood Pressure
 ​<130/80 mmHg
 ​May be less stringent in certain patients e.g. frail elderly ​
​Body Mass Index (BMI)
 ​<23 kg/m2​
 ​Or 5–​​10% body weight loss from diagnosis


May consider regular self blood glucose monitoring (SBGM). Also see recommended care components  and frequency of tests.​

The Healthier SG cardiovascular disease risk calculator​ may assist to determine the appropriate BP and LDL-cholesterol targets.


2. Lifestyle

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

  2. Smoking Cessation

  3. Regular physical activity, ↓​sedentary behaviour.

  4. Stress management - screen for depression (PHQ-2) .

  5. Weight reduction.

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.​


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 the MOH playbook on Care Team Education for Person-Centred Communication​.

​
4. Medication​3,4
(Adapted from the ACE Clinical Guidance on Type 2 Diabetes Mellitus: personalising management with non-insulin medications: 17 May 2023)​

  1. ​Consider Metformin as 1st line agent (after failing to meet glycaemic targets despite lifestyle changes alone).

  2. 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.

  3. 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.

  4. 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.

  5. ​Consider basal insulin initiation​ if glycaemic targets are not met despite optimal treatment with non-insulin T2DM medications.​​

  6. Please refer to the Healthier SG whitelist​ for a full list of subsidised drugs where percentage-based subsidies can be provided under the Healthier SG Chronic Tier (starting in early 2024).  GPs can purchase these drugs under MOH Special Pricing Agreements.


5. Education

    GPs should educate their patients on:

  1. Symptoms of hypoglycaemia and hyperglycaemia, 

  2. SGBM if deemed useful as part of their DM management  ​,

  3. Benefits of good adherence to medications,

  4. Insulin injection, if indicated,

  5. Good foot care practices​​,5,6 and

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

  7. Reason for regular reviews and clarity on what these would involve.


6. Vaccination7 - Influenza and Pneumococcal.

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


7. Regular Assessment7

  1. ​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​. 

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

  3. Referral pathways for patients with diabetic foot conditions:

8. Screen and Co-Manage other Comorbidities​

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 (T1DM) 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 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.

  3. 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 Healthier SG Annual Service Fee payments.

Diagnosis

  1. Diagnosis*
  2. CDMP Condition(s)*
  3. Diagnosis Year


Blood Glucose

  1. HbA1c (%)*
  2. Date*

Blood Pressure

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

Kidney assessment

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


Weight

  1. BMI (kg/m2), calculated from height*, weight*
  2. Waist circumference (in cm; mandatory to fill if weight is not feasible. Otherwise, optional field to fill)*
  3. Weight not feasible (if applicable)*
  4. Date*

Smoking History

  1. Smoking status (Never smoker, Ex-smoker, Current smoker)*
  2. Year started smoking (if smoker)
  3. No. of sticks smoked/day* (For never smoker or ex-smoker, input 0)*
  4. Stage of change: (i) Pre-contemplation, (ii) Contemplation, (iii) Preparation, (iv) Action, or (v) Maintenance
  5. Fagerstrom Test Score – For patients who are prepared to quit and are actively participating in a structured smoking cessation counselling programme. GPs can consider administering the Fagerstrom test to determine degree of nicotine dependence
  6. Date of Smoking Assessment 

Vaccination

  1. SDD Code*
  2. Date*
  3. Due Date of Next Dose
  4. I acknowledge that I have reviewed the results and care delivery provided, that the vaccinations done are clinically indicated as per MOH's prevailing guidelines​
  5. Vaccination Exception Condition(s) (if applicable)*
  6. COVID-19 Vaccination Dose Type*
  7. COVID-19 Vaccination Condition(s)*


Diabetic Retinal Photography (DRP)

  1. Conducted?*
    • Yes
    • No
    • NA: patient on active follow up with ophthalmologist#
    • ​NA: no perception of light in both eyes (complete blindness)#
  2. Date of DRP*#
  3. Results of DRP*
    • No abnormality detected
    • Ungradable
    • Diabetic maculopathy
    • Other abnormalities (e.g. cataract, glaucoma)
    • Unknown*
    • Non-proliferative diabetic retinopathy (NPDR); Mild NPDR
    • Non-proliferative diabetic retinopathy (NPDR); Moderate, severe or very severe NPDR
    • Non-proliferative diabetic retinopathy (NPDR); Unknown severity​
    • Proliferative retinopathy
  4. Follow up actions
    • Annual screening
    • Refer to ophthalmologist (indicate with or without urgency): With urgency
    • Refer to ophthalmologist (indicate with or without urgency): Without urgency
    • Repeat DRP in 6 months
    • Refer to A&E
    • Others (free text)​
  5. Other findings

# Notes:

  • 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 and GPs 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)​8

  1. Conducted?*
    • Yes
    • No
    • NA: patient on active follow up with orthopaedics, vascular surgery or podiatry#
    • ​​NA: patient has bilateral lower limb amputation above ankle joint#
  2. Date of DFS*#
  3. DFS outcome*# (refer to 2024 DFS ACG Guidance​)
    • Low risk for diabetic foot ulcers
    • Moderate risk for diabetic foot ulcers
    • High risk for diabetic foot ulcers
    • Active diabetic foot condition
    • Unknown#

# Notes:

  • 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.

  • 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 with higher medication needs who are Healthier SG enrollees can opt to use the Healthier SG Chronic Tier at their enrolled clinics, which provides percentage-based subsidies for selected chronic medications. 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 enrollees with DM can be found in the Healthier SG Enrollment Programme Agreement. ​