7 Steps process in type 2 diabetes

A polypharmacy review (following the 7-Steps approach) should ensure optimal management of T2DM and other conditions. It should include addressing aggravating lifestyle factors and consideration of the most appropriate medication at the right dose with regular review.

The following 7-Steps are intended as a guide to structure the review process.

Step 1: Aim: What matters to the patient?

Step 2: Need: Identify essential drug therapy.

Step 3: Need: Does the patient take unnecessary drug therapy

Step 4: Effectiveness: Are therapeutic objectives being achieved?

Step 5: Safety: Is the patient at risk of ADRs or suffers actual ADRs?

Step 6: Sustainability: Is therapy cost-effective and environmentally sustainable?

Step 7: Patient-centred: Is the patient willing and able to take therapy as intended?

The 7-Steps to appropriate polypharmacy demonstrate that the review process is not in fact a linear single event, but cyclical, requiring regular repeat and review (see figure below). The circle is centred on what matters to the individual, ensuring they are provided with the right information, tools and resources to make informed decisions about their medicines and treatment options. It should be used at both initiation and review of medicines.

The following 7-Steps are intended as a guide to structure the review process. They are also available as a pdf here.

See case studies for examples of applying the 7-step medication review process.

Step 1 - Aims - What matters to the individual about their condition(s)?

Process

Review diagnoses and consider:

Therapeutic objectives of drug therapy
Management of existing health problems
Prevention of future health issues, including lifestyle advice

Person specific issues to address

to prevent long-term diabetes complications
is there co-existing cardiovascular or renal disease? Any mental health issues?
maintaining good mental health

Step 2 - Need - Identify essential drug therapy

Process

Identify essential drugs (not to be stopped without specialist advice*)

Drugs that have essential replacement functions
Drugs to prevent rapid symptomatic decline

* with advice from healthcare professional with specialist interest

Person specific issues to address

insulin
sulfonylurea for immediate management of hyperosmolar symptoms

Step 3 - Does the patient take unnecessary drug therapy?

Process

Identify and review the continued need for drugs

what is medication for?
with temporary indications
with higher than usual maintenance doses
with limited benefit/evidence for use

with limited benefit in the person under review (see Drug efficacy & applicability (NNT) table)

Person specific issues to address

SU for immediate reduction of symptomatic hyperglycaemia
SU for long term use; pioglitazone and gliptins less effective than other sub-classes
co-prescribing of DPP-4i and GLP-1RA not appropriate, stop DPP-4i

Step 4 - Effectiveness - Are therapeutic objectives being achieved?

Process

Identify the need for adding/intensifying drug therapy to achieve therapeutic objectives

to achieve symptom control
to achieve biochemical/clinical targets
to prevent disease progression/exacerbation
is there a more appropriate medication to achieve goals?

Person specific issues to address

consider target dependent on other factors, e.g., frailty?
SGLT-2i and GLP-1RA have positive ASCVD and CKD outcome data
if co-existing ASCVD or CKD, SGLT-2i or GLP-1RA may be more appropriate than gliptin or pioglitazone

Step 5 - Safety - Does the patient have or is at risk of ADRs/side effects? Does the person know what to do if they are ill??

Process

Identify individual safety risks by checking for

appropriate individual targets
drug-disease interactions
drug-drug interactions (see ADR table)
monitoring mechanisms for high-risk drugs
risk of accidental overdosing

Identify adverse drug effects by checking for

specific symptoms/laboratory markers
cumulative adverse drug effects (see ADR table)
drugs used to treat side effects caused by other drugs

Medication Sick Day guidance

Person specific issues to address

if frail, is HbA1c less than 48mmol/mol. Reduce therapy
check renal function and dose adjust where necessary, e.g., metformin reduce dose if eGFR <45ml/min and stop if eGFR <30ml/min
women of child-bearing age – metformin and insulin are suitable in pregnancy but others are not. Individuals should be made aware of this
temporarily stop SGLT-2i, metformin and SU during dehydration illness

Step 6 - Sustainability - Is drug therapy cost-effective and environmentally sustainable??

Process

Identify unnecessarily costly drug therapy by

considering more cost-effective alternatives, safety, convenience

Consider the environmental impact of

Inhaler use
Single use plastics
Medicines waste
Water pollution

Person specific issues to address

metformin modified release less cost effective than standard release, but appropriate if previous gastrointestinal intolerance
if insulin therapy required, are reusable pens and cartridges suitable, rather than disposable pens?

Step 7 - Person-centeredness - Is the patient willing and able to take drug therapy as intended?

Process

Does the person understand the outcomes of the review?

Consider teach-back

Ensure drug therapy changes are tailored to individual’s preferences. Consider

is the medication in a form they can take?
is the dosing schedule convenient?
what assistance is needed?
are they able to take medicines as intended?

Agree and communicate plan

discuss and agree with the individual/carer/welfare proxy therapeutic objectives and treatment priorities
include lifestyle and holistic management goals
inform relevant health and social care providers of changes in treatments across the transitions of care

7 steps overview

Click on the table image below for an overview of key considerations at each step for an individual with T2DM.

See case studies for examples of applying the 7-step medication review process.