Table 3.
6STEP example case from the third year in the Leiden Medical School
| CASE |
|---|
| A male Caucasian patient (age 56 years) was recently diagnosed with diabetes mellitus type 2 during a medical evaluation for his life insurance. He was told to visit his general practitioner for follow-up and treatment. |
| You are his GP and see the patient today. He has no specific complaints and does not use any medication. He smokes 15 cigarettes per day and works as accountant and sits behind his computer all day. |
| Weight 95 kg, height 1.80 m. |
| Blood pressure: 145/80 mmHg. |
| Laboratory results: HbA1c 8.6%; glucose (fasting)10 mmol l−1; lipids normal. |
| Creatinine 80 µmol l−1 |
| Albumin 40 g l−1 |
| Medication: none |
| Write a 6STEP therapeutic plan for this patient. |
| 6STEP answer model |
| STEP 1 – EVALUATION OF THE PROBLEM |
| Diabetes mellitus type 2: no complaints, but HbA1c and glucose are elevated. Probably due to increased insulin resistance. Attributing factors: overweight (BMI = 29 kg m−2), smoking and sedentary lifestyle. Treatment is required because of possible complications. No current therapy. |
| STEP 2 – GOAL |
| Prevention of macro- and microvascular damage. (cardiovascular disease, retinopathy, neuropathy and nephropathy) |
| STEP 3 – TREATMENT OPTIONS |
| Dutch GP guideline DMII: non-drug: weight loss (dietary restriction, less salt, less fat, less calories), stop smoking, physical exercise. |
| Drugs: oral antidiabetics: 1. biguanide (metformin), 2. sulphonylurea derivatives, 3. thiazolidinediones and 4. insulin. |
| STEP 4 – INDIVIDUALIZED THERAPY |
| The patient is overweight: a normal BMI could resolve the DMII. Losing weight is important. The patient should start a daily programme of physical exercise and restrict calories in his diet. Ask whether he wants to be coached in this. The patient smokes: stopping smoking significantly contributes to the goal of therapy. Non-drug treatment alone is not sufficient at this moment. Metformin is the first step in the treatment for diabetics. Metformin is renally cleared. Renal function is OK (eGFR (MDRD) is 92 ml min−1 1.73 m−2), so normal starting dose of metformin is adequate. |
| STEP 5 – PRESCRIPTION |
| Lifestyle: lose weight 3 kg month−1, stop smoking, daily exercise of 30 min. Start metformin 500 mg orally twice daily |
| Emphasize the importance of the lifestyle changes and drug compliance. Inform patient about ADRs of metformin (gastrointestinal complaints) |
| STEP 6 – FOLLOW-UP |
| After 6 weeks follow-up: check HbA1c (target value < 7%), blood pressure (120/80 mmHg), weight (BMI < 27 kg m−2) and lifestyle changes (did he stop smoking? Does he exercise regularly?). If NOT OK check compliance and adjust dose of metformin. If OK then yearly follow-up for retinopathy, renal function, nephropathy (microalbuminuria), lipids (hyperlipidaemia). Check for ADRs of metformin (nausea, diarrhoea) |