INTRODUCTION. This 2021 paper is an update of the 2019 version. In this current update, two new items of information added. Firstly, the 2020 Consensus statement of the Taiwan Hypertension Society and the Taiwan Society of Cardiology on HPDM, provided recommendations on additional medications to be considered in uncontrolled morning or night blood pressure (BP) are noted.9 Secondly, the nephroprotective properties of the SGLT-2 inhibitors are highlighted.19 Similar to the content of the 2019 version, four related areas are reviewed. They are (1) BP definition and classification; (2) Hypertension diagnosis; (3) Hypertension and proteinuria in non-diabetic patients; and (4) Proteinuria and hypertension in the patient with diabetes. METHODOLOGY. PubMed searches were done for papers to the above four topics published in the last five years (2014 to 2019). These were supplemented by papers from hand searches. RESULTS. For diagnosis of hypertension, the current cut off of 140/90 mmHg can be reduced to 130/80 to improve cardiovascular outcomes and all-cause mortality. Diagnosis of hypertension should not be based on office BP readings alone. Hypertension in older patients should be treated to prevent worse outcomes and should be individualised. In non-diabetic patients, both low grade and microalbuminuria needs to be treated; adequate BP control is needed to prevent cardiovascular outcomes and all-cause mortality. In the diabetic patient, a BP target of less than 140/90 mmHg applies to most patients, but individualisation of the BP goal is important. CONCLUSIONS. Much development in the management of proteinuria and hypertension has taken place in the last five years.

Initiation of insulin therapy is challenging in the primary care setting without nursing support. Doctors have to prepare their practices to deal with these challenges in order not to delay insulin therapy when needed.

Obesity is now recognized as a chronic disease which needs chronic treatment to treat or prevent obesity related complications. This article discusses the biology of weight regulation as a basis to understanding obesity as a disease, and to appreciate the complex and multifactorial nature of the obesity problem. Finally, the article highlights the dietary approaches as part of the multi-pronged approach to treating obesity and gives a brief update on intermittent fasting.

Mr Tan, 60, a smoker with diabetes mellitus (DM), hypertension and chronic kidney disease (CKD) Stage 3, and recurrent gout flares last five weeks of increasing intensity and duration. He assumes it is due to frequent travel and lack of exercise. He comes today for routine review of his chronic diseases. Current laboratory results are creatinine 106, eGFR 56, uric acid 490, HbA1c 7.3%, random hypocount 8.5 mmol/L. He is on glipizide 5mg bd, Metformin 250mg BD, Amlodipine 5mg OM. He complains of severe gout pain. He had always been reluctant to start definitive treatment which you had previously mentioned. What will you do next?

Non-alcoholic fatty liver disease (NAFLD) has become the commonest chronic liver disease in the world. Overall improvement in public health, active screening of blood products, universal vaccination of hepatitis B have led to drop in incidence of hepatitis B and C worldwide. NAFLD is strongly associated with metabolic syndrome. With rise in overweight status and obesity worldwide, it is not surprising that NAFLD is on the rise. Diagnosis of NAFLD requires confirmation of fatty infiltration in liver, as well as liver damage like elevated liver enzymes and presence of fibrosis. Currently best treatment for NAFLD is weight loss, and the proven method would be dieting with regular exercises. Vitamin E and pioglitazoles are promising medications for treating NAFLD, but each has their shortcoming. Until more studies are conducted, lifestyle modification remains the only reliable way to treat NAFLD. Family physicians also ought to look out for cardiovascular diseases, as well as be vigilant in cancer screening, as NAFLD is associated with higher risks of ischemic heart disease and cancer.

Non-alcoholic fatty liver disease (NAFLD) has become the commonest chronic liver disease in the world. Overall improvement in public health, active screening of blood products, and universal vaccination of hepatitis B have led to a drop in incidence of hepatitis B and C worldwide. NAFLD is strongly associated with metabolic syndrome. With the rise in overweight status and obesity worldwide, it is not surprising that NAFLD is on the rise. Diagnosis of NAFLD requires confirmation of fatty infiltration in liver, as well as liver damage such as elevated liver enzymes and presence of fibrosis. Currently, the best treatment for NAFLD is weight loss, and the proven method would be dieting with regular exercises. Vitamin E and pioglitazoles are promising medications for treating NAFLD, but each medication has their shortcomings. Until more studies are conducted, lifestyle modification remains the only reliable way to treat NAFLD. Family physicians ought to look out for cardiovascular diseases, as well as being vigilant in cancer screening, as NAFLD is associated with higher risks of ischemic heart disease and cancer.

A rising prevalence of asthma in Singapore translates to a more considerable patient care burden for general practitioners. Along with diagnosing and managing the treatment of asthma, general practitioners must recognise when referral to a respiratory specialist is necessary. Although mild to moderate asthma is generally manageable in the primary care setting, patients with poorly controlled, difficult-to-treat, or severe asthma may benefit from referral to a specialist. Currently, many of these patients are not receiving optimal care, which places them at risk of asthma exacerbations and unnecessary systemic corticosteroid use. AsthmaID was developed as a tool for general practitioners to identify patients with asthma for whom a specialist evaluation could help improve asthma symptom control and optimise treatment strategies. Using four questions developed by asthma experts and rooted in the Global Initiative for Asthma report, AsthmaID quickly identifies patients who may benefit from a specialist referral without requiring additional patient assessments or testing modalities. Implementation of AsthmaID in clinical practice has the potential to transform the patient care pathway, thereby improving the quality of care for patients with asthma.

This case report of a 30-year-old type 2 diabetic patient illustrates the advantages of using real-time continuous glucose monitoring (rt-CGM) in a primary care setting. The patient was successfully weaned off subcutaneous insulin injections over a period of two months and achieved even better time-in-range outcomes. The patient is empowered with more insight into his metabolic condition and is currently trying new techniques such as intermittent fasting to further improve his diabetes.

Primary care providers are often the first to diagnose chronic kidney disease (CKD). CKD progression is associated with significant morbidity, mortality and cost to the public healthcare system. Prompt and appropriate initial evaluation of CKD, recognition of its complications, and instituting appropriate treatment will delay CKD progression and associated adverse outcomes.

Chronic kidney disease (CKD) is common worldwide and in Singapore. The primary care physicians play an important role in managing patients with CKD, especially in the early stages of CKD. The primary objectives of CKD management are (1) slowing down the progression of CKD, (2) managing the complications of CKD, and (3) establishing the longterm kidney care plan. The interventions to slow down the progression of CKD are to identify the cause of CKD, use the renin-aldosterone system blocker and the sodium-glucose cotransporter-2 inhibitor in suitable CKD populations, optimise blood pressure and glycaemic control, correct acidosis, avoid acute kidney injury and nephrotoxin, and modify dietary and lifestyle habits. For complications of CKD, the focus is on reducing cardiovascular risk, and managing anaemia, mineral bone disease, electrolytes imbalances and fluid overload. Lastly, there is a need to establish CKD patient’s treatment goals and initiate advanced care planning in a patient with progressive CKD to facilitate future care.