Approach to managing multimorbidity
Given the lack of clear evidence for specific multimorbidity interventions and the difficulty with following individual clinical guidelines, the following clinical principles are suggested to guide general practice management of multimorbidity in patients with type 2 diabetes.
Refer also to the chapter on ‘Multimorbidity’ in the RACGP aged care clinical guide (Silver Book).
Recognise clinical context and prognosis
Consider clinical management decisions within the context of risks, burdens, benefits, and prognosis of a patient’s life (eg remaining life expectancy, functional status, quality of life).29–31
Promote person-centred care
Focus on outcomes that matter most to the individual. Shared decision-making with patients is vital to ensure care is aligned with their values and preferences.6,31–34
Recognise and manage mental health issues, cognitive decline and socioeconomic deprivation.
Recognise the limitations of the evidence base
Many of the patterns of multimorbidity have similar pathogenesis and therapeutic management strategies (eg diabetes, hypertension, coronary artery disease). Focus on functional optimisation and on shared (concordant) risk factors.
Clinical guidance regarding discordant conditions, such as steroid-dependent conditions (which destabilise glycaemic control), or conditions that alter medication pharmacokinetics (eg renal disease, cardiac failure, liver disease, malabsorptive states), is often lacking or sparse.
A degree of clinical judgement and a ‘best care given the circumstances’ is required in these situations.9
Adherence to therapy can be much more difficult for patients taking numerous medications for multiple conditions. De-prescribing and reviewing medications, where indicated, may reduce medication burden.
Important drug interactions and side effects
People with diabetes may be taking multiple glucose-lowering medications in addition to other prescription and non-prescription agents. Some drug interactions are dangerous, and special care is required in older patients and patients with comorbidities such as renal impairment and autonomic neuropathy.
Polypharmacy (taking >5 medications) is one consequence of following single-disease guidelines in people with multimorbidity.15,31,35–37
Polypharmacy can be appropriate and has been said to be the price of success in creating effective treatments. However, it is also associated with higher rates of adverse drug events and hospitalisation, and is often particularly problematic in people who are physically frail38 or have cognitive impairment.
Use strategies for choosing therapies that optimise benefit, minimise harm and enhance quality of life, particularly in older adults with multimorbidity.
Plan regular (at least annual) reviews of medications.
Provide continuity of care, preferably through a single healthcare provider.
Ensure adequate time for consultations and set up practice systems to ensure regular review and best use of practice resources (eg scheduling concurrent practice nurse and doctor consultations) to address problems and develop patient-oriented solutions. This should allow adequate time for reaching management decisions.9
Use a coordinated, multidisciplinary team approach where appropriate.