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Management of Diabetes Mellitus (DM) in Primary Care Settings (continued)

Management strategy ^HbA1c goal (Module 5)

• Promote lifestyle modification, e.g. diet (Module 3), exercise Individualised, balancing benefits
(Module 4) and smoking cessation and risks
• Check HbA1c half yearly or more frequently if necessary • General: < 7%
(Module 5) and arrange regular follow up • Young and fit: ≤ 6.5%
• Measure BP every visit. Start ACEI / ARB for patients with HT • Frail elderly, severe
(BP ≥ 130/80 mmHg) (Module 7), microalbuminuria or hypoglycaemic episodes or
proteinuria (Module 9) advanced disease:
• Consider statin if lifestyle modification fails to achieve target Less stringent goal
LDL-C < 2.6 mmol/L (Module 8)
• Consider referral if indicated (Core Document 8.1)

HbA1c ≥ 7%^ after lifestyle modification

• Use Metformin as monotherapy (Module 6)
Step 1: • Consider sulphonylurea if:
Mono-therapy - Metformin not tolerated or contraindicated
- Rapid response desired for hyperglycaemic symptoms

HbA1c still ≥ 7%^ despite monotherapy

Add Sulphonylurea when Consider adding pioglitazone, DPP4 inhibitor or
Step 2: blood glucose control remains SGLT2 inhibitor instead of sulphonylurea if:
Dual therapy inadequate on metformin - Significant risk of hypoglycaemia
(Module 6)
- Intolerant of or contraindicated to sulphonylurea

HbA1c ≥ 7.5%^ despite adjustment /
addition of blood glucose lowering drugs

Step 3: • Consider insulin (Appendix of Module 6)
Triple therapy • Add Pioglitazone, DPP4 inhibitor or SGLT2 inhibitor when insulin is unacceptable
or insulin or inappropriate
based • Add GLP-1 agonist if BMI ≥ 35kg/m2 and weight loss would benefit comorbidities

Annual assessment and complication screening (Core Document 8.3)

• Glycaemic control • Complications
- HbA1c - Nephropathy (serum creatinine / random spot
- Compliance / diabetes knowledge urine albumin: creatinine ratio) (Module 9)
• Co-existing cardiovascular risk factors - Retinopathy (Module 10)
- Obesity (BMI / waist circumference) - Foot (foot pulse / foot ulcer /neuropathy)
- Smoking / alcohol (Module 11)
- HT (BP) • Medication review, dietary assessment
- Dyslipidaemia (lipid profile)

Note: [1] Values in diabetic range in 2 occasions in asymptomatic subjects for diagnosis
Source: Extracted from the Hong Kong Reference Framework for Diabetes Care for Adults in Primary Care Settings,
available at www.fhb.gov.hk/pho
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