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January 2019, Volume 69, Issue 1

Primary Care Diabetes

Difficult diabetes: the 7d approach

Sanjay Kalra  ( Department of Endocrinology, Bharti Hospital, Karnal )
Gagan Priya  ( Department of Endocrinology, Fortis Hospital, Mohali )
Rajat Gupta  ( Department of Endocrinology, Alchemist Hospital, Panchkula, India )


This communication describes a 7D approach to the assessment and management of ‘difficult’ or refractory type 2 diabetes. It lists 7 aspects of care, which may contribute to refractoriness of hyperglycaemia, and classifies them according to a bio-psychopharmacological triad. The biomedical aspects to be addressed include diagnosis of the type of diabetes and exclusion of comorbid disease. Psychosocial factors of importance include establishing effective dialogue with the patient, ensuring discipline in daily lifestyle, and minimizing diabetes related distress. Pharmacological factors which may cause difficulty in management pertain to inappropriate choice of drug or delivery device. A simple 7D checklist of factors which may lead to uncontrolled hyperglycaemia and indicate need for insulin therapy is also presented. The bio-psychopharmacological 7D approach serves as a simple, yet comprehensive, learning tool to help improve diabetes care.
Keywords: Type 2 diabetes, LADA, pancreatic diabetes, diabetes distress, insulin delivery, patient centered care, bio-psychosocial.


Refractory diabetes, or difficult diabetes, is a term used to describe persons with diabetes in whom glycaemic control is difficult to achieve1. Refractory diabetes has been discussed earlier as a psychosocial construct which may respond to appropriate patient – physician communication, also known as ‘diabetes therapy by the ear’2. The 5D mnemonic has also been developed to list common biomedical causes of refractoriness in diabetes Management3. However, earlier models of managing refractory diabetes have limited themselves to either soft skills or to biomedical issues.

Bio-Psycho-Pharmacological Framework

This communication provides a holistic rubric with which to approach poorly controlled diabetes. It includes both biomedical and psychosocial causes of uncontrolled hyperglycaemia, thus allowing the medical practitioner to practice a unified biopsychosocial therapeutic strategy. The bio-psycho-pharmacological framework, as we term it, specifies the need for dialogue or patient centered care, as being central to diabetes care4. Thus, it reinforces the importance of shared decision-making and team work in management. It underscores the need for comprehensive psychological, medical, endocrine and surgical assessment in diabetes care5,6. The triangular framework, depicted in figure 1, also highlights the pharmacological aspect of diabetes management and the need to choose drugs and delivery devices with due diligence.

The 7D Framework

The triad of psychosocial, biomedical and pharmacological causes of refractoriness of diabetes can be further expanded into a 7D framework, which lists 7 possible etiologies or contributory factors of uncontrolled hyperglycaemia as outlined in Table 1.

These include psychosocial factors7 such as suboptimal dialogue between patient and physician, lack of discipline in daily life, and psychological/ psychiatric distress. Biomedical issues8, such as reviewing the diagnosis of (type of) diabetes and screening for comorbid medical, surgical or endocrine disease also figure in the 7D list. The third angle of the bio-psycho-pharmacological tripod relates to drugs and delivery systems. Just as one must review the diagnosis of diabetes and other diseases in difficult to control diabetes, the choice of therapy and its delivery must be audited as well. Another suggested 7D alliterative list (Table 2)

includes a pathophysiologic classification of seven clinical situations which require immediate resolution of hyperglycaemia, preferably with insulin.


1. Kalra S, Talwar V. Refractory diabetes: focus on the obvious. J Pak Med Assoc 2017; 67: 146-7.
2. Kalra S, Baruah MP, Das AK. Diabetes therapy by the ear: A bidirectional
process. Indian J Endocr Metab. 2015; 19(Suppl 1):S4- S5.
3. Kalra S, Gupta V. Refractory diabetes: A 5 D approach. Submitted to J Ind Med Assoc, 2018
4. Wiebe DJ, Helgeson V, Berg CA. The social context of managing diabetes across the life span. Am Psychol 2016; 71:526.
5. American Diabetes Association. 8. Pharmacologic Approaches to Glycemic Treatment: Standards of Medical Care in Diabetes— 2018. Diabetes Care. 2018; 41(Supplement 1):S73-85.
6. Bajaj S. RSSDI clinical practice recommendations for the management of type 2 diabetes mellitus. Int J Diabetes Dev Ctries 2018; 38:1-15.
7. Kalra S, Sridhar GR, Balhara YP, Sahay RK, Bantwal G, Baruah MP, et al. National recommendations: Psychosocial management of diabetes in India. Indian J Endocr Metab 2013;17:376.
8. American Diabetes Association. 2. Classification and Diagnosis of Diabetes: Standards of Medical Care in Diabetes—2018. Diabetes Care. 2018 ; 41(Supplement 1):S13-27.
9. Kalra S, Gupta Y. Insulin initiation: bringing objectivity to choice. J Diabetes Metab Disord. 2015;14:17.

Journal of the Pakistan Medical Association has agreed to receive and publish manuscripts in accordance with the principles of the following committees: