We're aware of a cyber security incident affecting the electronic prescriptions provider MediSecure. The eRX Script Exchange (eRX) and the National Prescription Delivery Service (NPDS) continue to operate as usual and have not been impacted. Find out more and read our statement here.

Management of type 2 diabetes: A handbook for general practice

Managing multimorbidity in people with type 2 diabetes

Download chapter

Last revised: 17 Sep 2020

Multimorbidity is defined as the co-existence of two or more chronic conditions in the same patient.1 About half of the patients seen by general practitioners (GPs) in Australia meet this definition.2

Multimorbidity increases the risk of premature death, hospitalisation, functional impairment and deterioration in quality of life, in addition to increasing healthcare use and associated cost, polypharmacy and the complexity of self-care.3,4

Type 2 diabetes is associated with multimorbidity, which increases in prevalence and changes in composition over time. More than 80% of people with type 2 diabetes will have multimorbidity within 16 years of being diagnosed, and 47.6% have two or more conditions other than diabetes.5 The number of associated conditions increases with age, as people with diabetes live longer, partly as a consequence of improved treatment.6

Other well established determinants of multimorbidity include socioeconomic status and gender (higher prevalence in females).3 The prevalence of multimorbidity among Australian Aboriginal and Torres Strait Islander peoples is 2.59 times that of non-Indigenous Australians, a factor that contributes significantly to higher mortality.4,7

Multimorbidity in people with type 2 diabetes can lead to:8,9

  • premature mortality
  • reduced quality of life
  • increased healthcare use
  • high burden of treatment
  • loss of physical functioning
  • increased mental health problems
  • polypharmacy, with increased risk of drug interactions and adverse drug events
  • fragmentation of care.

Multimorbidities may or may not be diabetes-related, and can be either concordant or discordant with diabetes care.6

Concordant conditions have a similar risk profile to type 2 diabetes and share the same management goals. They are usually incorporated in the single-disease guidelines.

Discordant conditions are not related in pathogenesis to type 2 diabetes and do not share similar management goals. This may impact on quality of care.10–12

Common multimorbidity clusters found in people with type 2 diabetes are shown in Figure 1. Because of the complex relationships between co-existing conditions, guidelines based on single diseases may not provide evidence for optimal care.13–15 While many conditions have a concordant treatment focus (eg hypertension, dyslipidaemia, cardiovascular disease [CVD] and renal disease), others, such as depression, chronic obstructive pulmonary disease and painful conditions, may be discordant.14,16

Few studies have examined the effectiveness of specific interventions to improve outcomes in people with multimorbidity. Findings have been mixed, but suggest there is an improvement in health outcomes when interventions target specific risk factors for the comorbid conditions (eg CVD and depression) or areas of functional difficulty.8

On an individual level, multimorbidity can have a profound effect on a patient’s ability to self-care and balance different treatment needs across multiple conditions.6,14 In particular, people with discordant comorbidities will likely require extra support to prioritise goals of care and to self-manage diabetes.17

The literature suggests that care for multimorbidity should be person-centred, promoting achievement of agreed goals through self-management and focusing on quality of life.

The challenge for general practice is to optimise the care for these patients, taking into account co-existing physical or mental health disorders, age, and socioeconomic and cultural issues.

Prevalence of the 15 most common comorbidity clusters in type 2 diabetes

Figure 1.

Prevalence of the 15 most common comorbidity clusters in type 2 diabetes18

Adapted with permission from Lin P, Kent D, Winn A, Cohen J, Neumann P. Multiple chronic conditions in type 2 diabetes mellitus: Prevalence and consequences. Am J Manag Care 2015;21(1):e23–e34.

Common comorbidities with diabetes

Be aware of the following common comorbidities with type 2 diabetes.
  • Macrovascular disease
    • Includes coronary artery disease, hypertension, chronic heart failure and cerebrovascular disease
  • Obesity
  • Painful conditions (acute and chronic)
    • Common in patients with type 2 diabetes. Peripheral neuropathies and arthritis account for most causes of pain. Tendinopathy is also a common cause
  • Arthritis
    • Arthritis is particularly problematic, as it can reduce capacity for self-management
  • Fractures
    • Research has shown that overall fracture risks are significantly higher for men and women with type 2 diabetes
  • Obstructive sleep apnoea (OSA)
    • OSA or sleep deprivation from any cause can aggravate insulin resistance, hypertension and hyperglycaemia
  • Cancer
    • Diabetes is associated with increased cancer risk, including substantially elevated risks of pancreatic and liver cancer, and moderately increased risk of ovarian, cervical, breast, kidney, bladder and colorectal cancer19
  • Renal impairment
    • Diabetes-related kidney disease is one of the most frequent complications of diabetes. It is the leading cause of end-stage renal disease, accounting for approximately 50% of cases in the developed world.20 Refer also to the section Microvascular complications: Nephropathy
  • Cognitive impairment
    • Type 2 diabetes is associated with cognitive impairment21,22 and higher rates of dementia23
  • Mental health issues
    • Conditions such as diabetes-related distress, depression and anxiety can adversely affect practitioner–patient communication and the patient’s ability to live and apply the principles of a diabetes management plan and glycaemic control. They can also add to the burden of disease and reduce quality of life. Depression and diabetes are also associated with a significantly increased all-cause and CVD-related mortality
    • Some antipsychotic medications can increase the risk of developing diabetes. Olanzapine and clozapine are associated with higher rates of diabetes compared with other antipsychotic agents24
  • Dental problems
    • Dental problems such as periodontitis (ie localised inflammation of the supporting structures of the teeth due to a chronic bacterial infection) are more common in patients with diabetes. Periodontitis can result in tooth loss and other dental complications that can interfere with the diet
    • There is a two-way relationship between diabetes and periodontitis – the management of periodontitis may lead to a modest reduction in glycated haemoglobin (HbA1c) of approximately 0.4%.25–28 Inversely, improving glycaemic management may also improve the severity and complications associated with periodontitis
    • Early prevention and intervention may prevent permanent dental loss and aid in glycaemic control
    • Oral and periodontal health reviews should be incorporated into the systematic individualised care of patients with diabetes. GPs should ask patients about smoking status, pain, swelling or bleeding in the gums, and loose teeth. Examination of the gums should include looking for signs of inflammation, such as swelling and redness, recession of the gums and build-up of plaque/tartar
    • Information about dental health and diabetes can be found on the Diabetes Australia website

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

Manage medication

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.

Coordinate care

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.

  1. Britt H, Harrison C, Miller G, Knox S. Prevalence and patterns of multimorbidity in Australia Med J Aust 2008;189(2):72–77.
  2. Harrison C, Henderson J, Miller G, Brit H. The prevalence of diagnosed chronic conditions and multimorbidity in Australia: A method for estimating population prevalence from general practice patient encounter data. PLoS One 2017;12(3):e0172935.
  3. Violan C, Foguet-Boreu Q, Flores-Mateo G, et al. Prevalence, determinants and patterns of multimorbidity in primary care: A systematic review of observational studies. PloS One 2014;9(7):e102149.
  4. Hussain M, Katzenellenbogen J, Sanfilippo F, Murray K, Thompson S. Complexity in disease management: A linked data analysis of multimorbidity in Aboriginal and non-Aboriginal patients hospitalised with atherothrombotic disease in Western Australia. PLoS One 2018;13(8):e0201496.
  5. Pouplier S, Olsen M, Willadsen T, et al. The development of multimorbidity during 16 years after diagnosis of type 2 diabetes. J Comorb 2018;8(1):2235042X18801658.
  6. Piette J, Kerr E. The impact of comorbid chronic conditions on diabetes care. Diabetes Care 2006;29:725–31.
  7. Randall D, Lujic S, Havard A, Eades S, Jorm L. Multimorbidity among Aboriginal people in New South Wales contributes significantly to their higher mortality. Med J Aust 2018;209(1):19–23.
  8. Smith S, Wallace E, O’Dowd T, Fortin M. Interventions for improving outcomes in patients with multimorbidity in primary care and community settings. Cochrane Database Syst Rev 2016;3:CD006560.
  9. Wallace E, Guthrie B, Fahey T. Managing patients with multimorbidity in primary care. BMJ 2015;350: h176.
  10. O’Shea M, Teeling M, Bennett K. Comorbidity, health-related quality of life and self-care in type 2 diabetes: A cross-sectional study in an outpatient population. Ir J Med Sci 2015;184:623–30.
  11. An J, Le Q, Dang T. Association between different types of comorbidity and disease burden in patients with diabetes. J Diabetes 2019;11:65–74.
  12. Chang A, Gomez-Olive F, Manne-Goehler J, et al. Multimorbidity and care for hypertension, diabetes and HIV among older adults in rural South Africa. Bull World Health Organ 2019;97(1):10–23.
  13. Salisbury C, Man M, Bower P, et al. Management of multimorbidity using a patient-centred care model: a pragmatic cluster-randomised trial of the 3D approach. Lancet 2018;392(10141):41–50.
  14. Harris M, Dennis S, Pillay M. Multimorbidity: Negotiating priorities and making progress. Aust Fam Physician 2013;42(12):850–54.
  15. World Health Organization. Multimorbidity: Technical Series on Safer Primary Care. Geneva: WHO, 2016.
  16. Freund T, Kunz CU, Ose D, Szecsenyi J, Peters-Klimm F. Patterns of multimorbidity in primary care patients at high risk of future hospitalization. Popul Health Manag 2012;15(2):119–24.
  17. Kerr E, Heisler M, Krein S, et al. Beyond comorbidity counts: How do comorbidity type and severity influence diabetes patients’ treatment priorities and self-management? J Gen Intern Med 2007;22(12):1635–40.
  18. Lin P, Kent D, Winn A, Cohen J, Neumann P. Multiple chronic conditions in type 2 diabetes mellitus: Prevalence and consequences. Am J Manag Care 2015;21(1):e23–e34.
  19. Starup-Linde J, Karlstad O, Eriksen S, et al. CARING (CAncer Risk and INsulin analoGues): The association of diabetes mellitus and cancer risk with focus on possible determinants – A systematic review and a meta-analysis. Curr Drug Saf 2013;8(5):296–332.
  20. Tuttle K, Bakris G, Bilous R, et al. Diabetic kidney disease: A report from an ADA Consensus Conference. Diabetes Care 2014;37(10):2864–83.
  21. Palta P, Schneider AL, Biessels GJ, Touradji P, Hill-Briggs F. Magnitude of cognitive dysfunction in adults with type 2 diabetes: A meta-analysis of six cognitive domains and the most frequently reported neuropsychological tests within domains. J Int Neuropsychol Soc 2014;20(3):278–91.
  22. Monette MC, Baird A, Jackson DL. A meta-analysis of cognitive functioning in nondemented adults with type 2 diabetes mellitus. Can J Diabetes 2014;38:401–18.
  23. Barbagallo M, Dominguez LJ. Type 2 diabetes mellitus and Alzheimer’s disease. World J Diabetes 2014;5(6):889–93.
  24. Hirsch L, Yang J, Jette N, Bresee L, Patten S, Pringsheim T. Second-generation antipsychotics and metabolic side effects: A systematic review of population-based studies. Drug Saf 2017;40(9):771–81.
  25. Morita I, Inagaki K, Nakamura F, et al. Relationship between periodontal status and levels of glycated hemoglobin. J Dent Res 2012;91(2):161–66.
  26. Preshaw PM, Alba AL, Herrera D, et al. Periodontitis and diabetes: A two-way relationship. Diabetologia 2012;55(1):21–31.
  27. Simpson TC, Needleman I, Wild SH, Moles D, Mills E. Treatment of periodontal disease for glycaemic control in people with diabetes. Cochrane Database Syst Rev 2010;(5):CD004714.
  28. Teeuw WJ, Gerdes VE, Loos BG. Effect of periodontal treatment on glycemic control of diabetic patients: A systematic review and meta-analysis. Diabetes Care 2010;33:421–27.
  29. Guthrie B, Payne K, Alderson P, McMurdo M, Mercer S. Adapting clinical guidelines to take account of multimorbidity. BMJ 2012;345:e6341.
  30. Boyd CM, Fortin M. Future of multimorbidity research: How should understanding of multimorbidity inform health system design? Public Health Reviews 2010;32:451–74.
  31. American Geriatrics Society Expert Panel on the Care of Older Adults with Multimorbidity. Guiding principles for the care of older adults with multimorbidity: An approach for clinicians. J Am Geriatr Soc 2012;60:e1–e25.
  32. Boult C, Wieland GD. Comprehensive primary care for older patients with multiple chronic conditions: ‘Nobody rushes you through’. JAMA 2010;304:1936–43.
  33. Healthcare Improvement Scotland. Living with multiple conditions: Issues, challenges and solutions. Edinburgh: HIS, 2012.
  34. Noel PH, Parchman ML, Williams JW Jr, et al. The challenges of multimorbidity from the patient perspective. J Gen Intern Med 2007;22 Suppl 3:419–24.
  35. Calderon-Larranaga A, Poblador-Plou B, Gonzalez-Rubio F, Gimeno-Feliu LA, Abad-Díez JM, Prados-Torres A. Multimorbidity, polypharmacy, referrals, and adverse drug events: Are we doing things well? Br J Gen Pract 2012;62(605):e821–26.
  36. Schiff GD, Galanter WL, Duhig J, Lodolce AE, Koronkowski MJ, Lambert BL. Principles of conservative prescribing. Arch Intern Med 2011;171(16):1433–40.
  37. Vyas A, Pan X, Sambamoorthi U. Chronic condition clusters and polypharmacy among adults. Int J Family Med 2012;2012:193168.
  38. Rijken M, Bekkema N, Boeckxstaens P, Schellevis FG, De Maeseneer JM, Groenewegen PP. Chronic Disease Management Programmes: An adequate response to patients’ needs? Health Expect 2012;17(5):608–21.
This event attracts CPD points and can be self recorded

Did you know you can now log your CPD with a click of a button?

Create Quick log