Clinical practice guidelines are series of recommendations to assist practitioner on clinical care supported by scientific evidence base. They were systematically developed guided by research evidence and values to assist fair decision and judgement at the clinical management level. Ministry of Health is committed in improving these guidelines. This guideline was developed by the committee which comprises by the experts from the College of Family Practitioners Singapore, other Professional Societies, Academy of Medicine Singapore, and patient representatives (Ministry of Health). These stakeholders will seat together and brainstorm with a certain topic and developed a standard guideline for this topic at a prolong period of time supported by scientific evidence base. These guidelines serve as education tools for patient and promote best practices for medical practitioners in their area of practice. One of the aims of CPG is to standardise, guide practice, inform general pattern of care, and reduce variations in healthcare practices in local setting. One of which is on the management of Diabetes Mellitus as this disease is rapidly increasing.
According to Porth & Matfin Diabetes Mellitus is a disorder of carbohydrate, protein and fat metabolism resulting from an imbalance between insulin availability and insulin need.
Diabetes Mellitus is a major illness that affects all age group worldwide and estimated that at least 1 in 20 deaths attributes by Diabetes. According to National Health Survey in Singapore conducted last 2004, diabetes is the eight commonest cause of death and the prevalence was 8.2%. In year 2010, the National Health Survey showed that 11.3% of those aged 18-69 have Diabetes (Singapore MOH Statistics 2010). By year 2030, estimated number of people with diabetes will be more double. Studies showed that evidence-based guidance provided in most guidelines can have major beneficial effects in patients (MOH Singapore CPG 2006). Early diagnosis and aggressive treatment can prevent major chronic complications including microvascular and macrovascular disease. Early detection of DM therefore important as this is a lifelong disease. It is therefore the work of the committee to provide recommendations regarding diagnosing and detecting Diabetes in Singapore setting. It is then this group work together closely, studies and examined the recommendations of the American Diabetes Association, the European Diabetes Epidemiology Group, the World Health Organization, and the International Diabetes Federation. Then local recommendations drew out.
On the year 1993, the National Diabetes Commission in Singapore first drew the guidelines for the management of diabetes mellitus. On the year 1999, the clinical practice guidelines for diabetes mellitus were published by the MOH. Since then, more facts emerged about diabetes not only on diagnosis and treatment but also on the prevention. These guidelines for the management of Diabetes Mellitus created mainly to help medical practitioners on their clinical decision on diabetes supported by evidence base and up to date information about the disease and provides a general pattern of care. The committee advises to review the guidelines after 4 years or earlier after publication as new evidence and recommendations may arise.
Revised Clinical Practice Guidelines
On the year 1997/1998, the diagnosis of diabetes mellitus and other categories of glucose tolerance underwent a significant change. Certain clinical practice guidelines were revised in Singapore CPG. One of which is on the latest update on the pharmacotherapy in diabetes mellitus. The prevention of cardiovascular and diabetic nephropathy has been extensively revised. Prevention and management of eye complications has been updated. Pregestational and gestational diabeteshas been updated. Use of appropriate biguanides for childhood and adolescent diabetes mellitus has new data. Prevention of type 2 diabetes mellitus and cost benefit issues has been added. Clinical quality indicators for diabetes have been updated. 10 multiple choice questions for self assessment have been added.
Diagnostic Criteria for DM in Singapore
Diagnosis for diabetes mellitus remains unchanged from the previous MOH CPG 1999. For diagnosing diabetes, no further testing is required to diagnose DM if unequivocal hyperglycemia is noted with acute metabolic decompensation, example hyperosmolar non-ketotic hyperglycemia coma and diabetic ketoacidosis. For symptomatic individual, diagnosis can be made on any one of the following criteria: if casual plasma glucose is more than 11.1mmol/l (casual means any time of the day), fasting plasma glucose is more than 7.0mmol/l (fasting means no calorie intake for at least 8hours), or 2 hour post challenge plasma glucose is more than 11.1mmol/l. It is recommended that all fasting plasma glucose of 6.1 to 6.9mmol/l be subjected to an oral glucose tolerance test (75g glucose) to determine the glycemic status. Fasting plasma glucose is the choice to test for the diagnosis of diabetes mellitus. For asymptomatic individual, with high risk of type 2 diabetes should begin at the age of 40 years and be considered at the age of 30 years if risk factors are present. For fasting plasma glucose is more than 7.0mmol/l and repeated fasting plasma glucose is 7.0mmol/l, individual can diagnose with DM. For those with normal glucose tolerance should screen every 3years and annually for those with impaired glucose tolerance. Investigations required for visit at the clinic: fasting plasma glucose/2hpp, blood pressure taking, weight, and body mass index. Blood test HbA1C to be done every 3 months. To be done yearly comprises of the following: DM panel test comprising HbA1C, lipid profile, serum creatinine, UACR, ECG, diabetic foot screening, and diabetic retinal photography.