Unstable and Brittle Diabetes (Advances in Diabetes)

The concept of brittle diabetes was first introduced in the 1940s to categorize people with type 1 diabetes who didn’t seem to respond well to insulin treatment.

In the mid-20th century, before personal blood glucose meters became available, blood glucose measurements were hard to come by, so the defining features of brittle diabetes were unexpected episodes of low blood glucose (hypoglycemia) as well as recurrent diabetic ketoacidosis (DKA), a severe complication of very high blood glucose.

Today, people have a much more detailed picture of how blood glucose changes over the course of a day, thanks to blood glucose meters and continuous glucose monitors.

Because blood glucose fluctuations now are easier to track, people may be amazed at just how frequently levels vary.

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One of the most prominent features of diabetes is its uniqueness. No two diabetics respond in exactly the same way to their food, insulin, or exercise, and no two individuals, even if they show the same glucose test results, will experience precisely the same complications.

The disease is, by definition, unpredictable. Still, making allowance for surprises, we know the effects of more insulin, less insulin, more exercise, less exercise, more food, etc.

For most diabetics, most of the time, the “rules” work. “If I do this, or do not do that, I can expect this result.”

But there is a body of individuals for whom the rules do not appear to apply, and to them is often applied the adjective “brittle.”

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“Brittle” describes a severe form of diabetes. It’s characterized by an up and down of blood sugar levels. These swings in glucose can affect quality of life and even lead to hospitalization.

Advances in diabetes management have made this condition uncommon, but brittle diabetes is still a concern among diabetics. It’s also a sign that your blood sugar is poorly managed.

But for the most part, it’s considered an outdated label that’s faded drastically in the past 15 years.

Many medical experts now try to discourage its use, saying the term’s  only leads to confusion.

But some disagree, saying “brittle diabetes” refers not to everyday ups and downs, but rather to a rare but real condition in which the diabetic has volatile blood sugar swings that are nearly impossible to control.

It’s known as labile diabetes in clinical lingo and there are some in the diabetic community advocating to bring more awareness and recognition to this rare and severe form of Type 1 Diabetes.

1.Labile Diabetes

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Almost all diabetic patients experience swings in blood glucose levels, which are larger and less predictable than in nondiabetics.

When these swings become intolerable and cause disruption to the person’s daily life and/or prolonged hospitalization, the person is labeled as having “labile” or “brittle” diabetes.

Although brittle diabetes is uncommon (less than 1 percent of insulin-taking diabetic patients) , it can cause a considerable burden on hospital, social, and family resources due to multiple hospital admissions.

Most experts would define brittle diabetes as severe instability of blood glucose levels with frequent and unpredictable episodes of hypoglycemia and/or ketoacidosis that disrupt quality of life.

The unpredictable episodes of hypoglycemia and/or ketoacidosis are due to an absolute insulin dependency (undetectable C-peptide levels).

C-peptide measurements play a key role in the evaluation of hypoglycemia and insulinoma, are a useful aid in the classification of diabetes mellitus, and may play a larger role in its management in the future.

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2.Insulinoma

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Insulinoma is a tumor of the pancreas that produces excessive amounts of insulin. Insulinomas are more common in women. The tumors are usually small (less than 2cm) and more than 90% of all insulinomas are benign (non-cancerous).

Insulinomas produce excessive amounts of insulin and this causes low blood sugar.

The typical symptoms that patients complain about are related to the development of low bloods sugar and include tiredness, weakness, tremulous and hunger.

Many patients have to eat frequently to prevent symptoms from the low blood sugar.

Some patients may develop psychiatric symptoms because of the low blood sugar.

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3.Risk Factors And Symptoms Of Brittle Diabetes

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Researchers have come up with various explanations, both mental and physical, to explain why some people have more variation in blood glucose than others.

People who don’t take medication as prescribed, perhaps because of psychological issues, may be more likely to experience unexpected fluctuations.

On the physical side, gastroparesis, a diabetic complication associated with nerve damage, affects the speed and consistency of digestion.

People with this condition may have problems synchronizing insulin dosing with the glucose absorption from the food they eat, resulting in blood glucose fluctuations.

Imbalances in hormones, such as glucagon, can also influence blood glucose variability.

The ability to make insulin may be what separates brittle from regular diabetes.

People with type 1 diabetes are unable to produce enough insulin to control blood glucose levels, but recent research suggests that some Type 1 diabetics can still make some insulin.

And those insulin producers tend to have fewer glucose fluctuations than those who don’t make any insulin.

If the pancreas can make a little bit of insulin, it serves as a buffer against dramatic blood glucose changes.

Hypo- and hyperglycemic symptoms are common signs of brittle diabetes due to fluctuations in blood sugar.

Extremely low blood sugar can cause:

The most effective treatment for brittle diabetes is to identify and correct underlying physical or psychological problems. Glucose instability is often able to be tracked using blood tests.

Often treatment seeks to address behavioural, psychological or environmental causes. This can be a lengthy and difficult process of treatment.

Treatment may involve trying to lessen stress, and psychotherapy has also proven to be effective in the treatment of brittle diabetes.

Smoothing out the dips and surges of blood glucose depends on identifying the many possible causes of the fluctuations.

If psychological issues are behind brittleness, treatment with medication or counseling may help iron out things.

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For example, with gastroparesis, changing one’s diet and eating patterns, alongside medications and gastric pacing devices, can improve the consistency of digestion and level out blood sugar levels.

Undiagnosed or uncontrolled celiac disease can result in varied absorption of food and unexplained blood sugar swings.

Whether you call it brittle diabetes or just variability, there are options for people who have a hard time getting blood glucose to level out.

People with brittle diabetes, who are motivated to participate in their diabetes care and are technologically adept, may benefit from continuous glucose monitoring.

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Current continuous glucose monitoring systems indicate the glucose level, the direction and magnitude of change of glucose levels, and can be used to assess glycemic variability.

In addition, real-time continuous glucose monitoring sensors can serve as a tool to predict impending glucose levels, thereby providing alarm signals of hypo- and hyperglycemic values warning the patient to take preventative actions.

Quality of life may also improve by using continuous glucose monitoring via reducing the fear of hypoglycemia.

Therapy of brittle diabetes is based on education, glycemic control, intensive treatment and strict interaction between doctors and diabetic patients.

After identifying what’s causing the fluctuations, yourself and your doctor can come up with an individualized treatment plan to smooth out the ups and downs as much as possible.

The patient’s ability to manage his or her own diabetes should be evaluated and reinforced if necessary, and guidelines drawn up with the diabetics agreement for future treatment targets and follow-up.

Diabetics should be educated on self-management and insulin dose adjustments, since a main cause of brittle diabetes is failure of the patient to understand or manage his or her own diabetes.

Behaviors that may contribute to hypoglycemia, such as taking excess insulin, delaying or missing meals, mistiming insulin/food intake around exercise, not monitoring before bed and appropriate increased food intake.

Alcohol consumption can also lead to hypoglycemia and impair recovery from a hypoglycemic episode.

Additionally, Diabetics are advised to have a glucagon emergency kit on hand for severe hypoglycemic episodes.

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Causes of unexplained hypoglycemia include life-style problems (unexpected stresses, erratic food habits, etc.), gastroparesis (slow and unpredictable emptying of food from the stomach), erratic insulin absorption from injection sites (especially if there is a buildup or breakdown of fat below the skin), and other factors. All of these should be reviewed with your doctor.

For erratic life-style issues, a more structured program is helpful. For gastroparesis, medications such as Reglan, Motilin, or Cisapride may be effective, as may having some liquid portion at each meal. Remember that fat tends to be released from the stomach more slowly in all people.

For areas of abnormal fat buildup or breakdown under the skin (lipohypertrophy or lipoatrophy), avoiding those sites can improve constancy of insulin absorption. Sticking to one site for injections, such as the abdomen, may also be helpful.

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Another aid to people with hypoglycemia may be the new analog insulins which act very rapidly, and can be administered in small doses shortly before a meal. Because their course of action should be shorter and therefore more predictable, the chance of hypoglycemia should be minimized.

Diabetics with brittle diabetes may sometimes need to be transferred to a different diabetes care team or center for a fresh start managing their diabetes. Switching to a specialty diabetes center can sometimes help to break the cycle of brittle diabetes.

Treating brittle diabetes sometimes requires a prolonged hospital stay of a few weeks with intensive monitoring of food, glucose and insulin.

People whose brittle diabetes is caused primarily by physical, rather than psychological, factors may benefit from a continuous insulin pump to control glucose levels precisely.

Women are more likely to develop brittle diabetes than men are. And, this can be compounded by the fact that both hormonal imbalances and existing hypothyroidism (more prevalent in women) are also risk factors.

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High levels of stress and being overweight are additional risk factors. Those who are in their 20’s and 30’s are also more likely to develop the condition.

Those who delayed a diagnosis of diabetes may also have a greater risk because this can lead to the condition becoming more poorly managed.

The earlier that a diagnosis of diabetes is made; the easier it is to control and manage. Additionally, earlier diagnoses also help to instill good habits and care regimens early on, thereby reducing the risk of poorly managed disease later in life.

The most important component of treating brittle diabetes is close supervision by the diabetics diabetes care team to treat underlying causes, ensuring that the diabetic receives and understands all necessary education, and supporting the diabetic and their family on the path to effective diabetes management.

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