Diabetes Over View

Brittle Diabetes

Introduction

Diabetes is unique, which is one of its prominent features, because 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. This makes the disease unpredictable making allowance for surprises.

Although for most diabetics, most of the time the rules work 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."

The problem becomes separating the truly "brittle" diabetics from the non-compliant, the poorly-controlled, or those whose unstable sugars have other explanations. Some have insisted that if all diabetics diligently practiced "tight control", none would be "brittle." Some time the numbers would go down, but some diabetics can do everything right and still remain "brittle."

What is Brittle Diabetes?

A term used when a person’s blood glucose level often swings quickly from high to low and from low to high. Also called labile and unstable diabetes. These are the diabetics, even practicing tight control, whose blood glucose level "over-reacts" to minute changes in diet, exercise, and/or insulin. These individuals experience unpredictable rises and swoops in blood glucose, within very short periods, as the result of very small departures from schedule. Small changes "break" their control, and they are thus said to be "brittle."

Brittle Diabetes is a subjective term and the diagnosis often depends on the experience of the patient, family and physician involved. The most useful definition of brittle diabetes is a functional one the patient whose life is constantly disrupted by episodes of hyper- or hypoglycemia, whatever their cause. While these patients are rare (less than one percent diabetics), they cause a considerable burden on hospital, social, and family resources due to multiple hospital admissions.

Many early studies tried to identify possible physiological mechanisms for the brittleness but with increasing study, it has become clear that the majority of cases are due to psychological factors. Metabolic abnormalities are a rare cause of poor glycemic control.

If you are practicing tight control, are in good compliance with your schedule, and are still experiencing rapid, out-of-proportion blood glucose changes, talk to your doctor. You (or more correctly your diabetes) may be "brittle," but your instabilities may well be a sign of some other problem.

Causes

• Not drawing up the same amount of insulin each time, even though you think you are.
• Delay in the absorption of Regular insulin.
• Variation in the absorption of Regular insulin.
• Variation in the absorption of other insulins.
• Different injection sites.
• Changing how deep the injection goes.
• Tobacco
• Skin too cold or too hot
• Injecting into a site that's going to be exercised.
• Dehydration
• The release of hormones that work against the action of insulin.
• Repeated and severe low blood glucose (hypoglycemia).
• Nerve damage.
• Insulin antibodies

It is clear that the brittleness in most patients is related to a specific unhappy life situation; when this resolves, so does the brittleness. Hyperglycemic brittleness is rarely related to a chronic cryptic infection. Hypoglycemic brittleness is rarely related to diabetic gastroparesis where the stomach has a delay in emptying or hypoglycemic unawareness where the patient cannot sense a low blood sugar.

Treatment

The approach to management will obviously vary depending on the specific cause in each case. In evaluating a patient with brittle diabetes, it may be beneficial to start fresh with a new physician and diabetes care team. A fresh look is helpful in remaining objective, decreasing the ability of the patient to manipulate the care team and possibly spot a metabolic cause, which may have been missed.

It is important to take a detailed history and do a detailed physical exam. It should also be determined if there was a period of "stable" diabetes preceding the brittleness, and what happened in the patient's life circumstances coincident with the onset of brittleness.

A diabetic educational assessment is important to evaluate whether the patient knows how to manage diabetes, and whether the current insulin regimen is reasonable. In addition, as many as one third of patients with brittle diabetes have been found to have a "communication disorder" as the major cause of their brittleness; specific treatment is beneficial in 75% of cases.

A psychological evaluation is always warranted, since psychotherapy has been shown to be effective in selected patients. Family counseling is also often necessary.

For severe cases of brittle diabetes, a structured hospital admission may be necessary. Generally these admissions are prolonged, lasting for two to three weeks. Pre-hospital planning is important and insurance pre-certification is often necessary. Early in the hospital course, the patient must be monitored closely and have all diabetes care done by the hospital staff. Gradually, the patient is allowed to become more involved in his or her own care. Intensive diabetes education is necessary as well as ongoing psychological support.

What else

Real "brittle diabetes" doesn't follow patterns. Individuals whose diabetes is "brittle" experience unpredictable, out-of-proportion rises and swoops in blood glucose, within short periods of time, as a result of very small deviations from schedule. Talk to your doctor, and to your health care team. They should help you set up an individualized testing program that will reveal what's going on--and then give you the tools to deal with it.