1.1 Development of guidelines

 

The first edition of the MOH clinical practice guidelines on diabetesmellitus for Singapore was published in 1999. Since that time, more factsabout this important condition have emerged, not only with regard to itsdiagnosis and treatment, but also about whether or not type 2 diabetesmay be prevented, and, if so, how this may be achieved.As diabetes mellitus has great public health significance in developedcountries and developing nations alike, managing it properly involves aconsideration, not just of clinical issues, but also of health economics.This second edition of the guidelines attempts to address some of thesecomplex issues wherever evidence-based information pertaining to themis available.

 

1.2 Objectives

 

The main aim of these guidelines is to help physicians make sound clinicaldecisions about diabetes mellitus by presenting up-to-date informationabout diagnosis, classification, treatment, outcomes, and follow-up.These guidelines are developed for all health care professionals inSingapore. We hope they would be helpful especially to primary carephysicians who care for patients with diabetes mellitus.

 

1.3 What’s new in the revised guidelines

 

The following is a list of the major revisions and additions to the previousguidelines:

 

The diagnosis of diabetes mellitus and other categories of glucosetolerance underwent a significant change in 1997/1998. In late 2003,the American Diabetes Association proposed another newmodification to the diagnostic criterion for impaired fasting glucose(IFG). Chapter 2 addresses this, and presents an update on howclinicians should diagnose and screen for diabetes and glucoseintolerance.

 

Chapter 5 on pharmacotherapy in diabetes mellitus has been updatedto take into account recent clinical trial evidence of the efficacy ofthe newer classes of antidiabetes drugs.

 

Chapter 7 on prevention of cardiovascular disease in diabetes mellitushas been extensively revised to address clinical targets for bloodpressure and lipids. Recommendations on decision-making in the areaof therapeutics have also been updated.

 

Chapter 8 on prevention and management of diabetic nephropathyhas been revised to present recent clinical trial evidence regardingthe efficacy of, and indications for, the use of angiotensin convertingenzyme inhibitors and angiotensin receptor blockers.

 

Chapter 9 on the prevention and management of eye complicationshas been updated. Additionally, the new guidelines include a set ofcolour plates of retinal photographs (Annex 1, page 151). We hopethe visual information these plates present would help physiciansrecognize diabetic retinal disease more readily, and take theappropriate clinical actions.

 

Chapter 11 on pregestational and gestational diabetes mellitus hasbeen updated.

 

Chapter 12 on childhood and adolescent diabetes mellitus has newdata on the appropriate use of biguanides in these patient groups.

 

Chapter 13 is a new chapter that addresses prevention of type 2diabetes mellitus. It reviews important information arising out ofrecent clinical trials designed to find out if type 2 diabetes mellituscould be prevented.

 

Chapter 14 addresses cost-benefit issues in diabetes mellitus.

 

Chapter 15 provides an update on clinical quality indicators fordiabetes. Patients with diabetes are catagorised into ‘at risk’ and’‘highrisk’ individuals and recommended frequency to measure differentquality indicators is specified for each category e.g HbA1c should bemeasured 6 monthly for ‘at risk’ and 3-4 monthly for ‘high risk’diabetes patients.

A new section on self-assessment containing 10 multiple choicequestions has been added.

 

1.4 Review of guidelines

 

Evidence-based clinical practice guidelines are only as current as theevidence that supports them. Users must keep in mind that new evidencecould supercede recommendations in these guidelines. The workgroupadvises that these guidelines be scheduled for review four years afterpublication, or earlier if new evidence emerges that necessitates substantivechanges to the recommendations.