Brittle diabetes

Unstable or brittle diabetes defines a subgroup of type 1 diabetes which is characterized by glycemic instability (extreme variations in blood sugar levels), regardless of its cause, with frequent episodes of ketoacidosis and hypoglycemia that occur rapidly and unpredictably. This leads to repeated and prolonged hospital admissions. It is important to note that glycemic instability leads to a disorganized lifestyle for the patient due to episodes of both hypoglycemia and hyperglycemia.

Some authors divide this type of diabetes into:

• True unstable diabetes – where the causes and mechanisms of glycemic instability are not evident;
• False unstable diabetes – where the glycemic variability has identifiable causes.

Identifying these cases of diabetes is important for therapeutic purposes, which aim to either change the insulin strategy or to take the decision of using an insulin pump.

What leads to brittle diabetes?

We have the organic factors which include:

• Ongoing eating disorders
• Disorder in physical activity
• Alcohol abuse and drug consumption
• Recurrent Somogyi effect
• Exaggerated Dawn effect
• Hidden infections: dental, ear, sinus, urinary, respiratory
• Endocrine disorders: hyperthyroidism, Addisson’s disease
• Gastrointestinal diseases: celiac disease, gastroparesis
• Hyperglycemic medications: corticosteroids, diuretics, etc.
• Self-induced treatment errors due to excessive concern about their blood sugar, leading the patient to adopt compulsive, sudden actions like over-insulinization or under-insulinization (due to fear of hypoglycemia)
• Stress: emotional, leading to decision-making errors in treatment administration
• Eating behavior disorders and the omission of insulin injections
• Behavioral disorders inducing instability: factitious ketoacidosis and factitious hypoglycemia
• Educational and psycholinguistic disorders: difficulties in processing information and making decisions
• Patient-doctor communication issues
• Manipulative behavior

And the psycho-social factors:

• Emotional or behavioral stress
• Eating disorders or disruptions in insulin administration

How often is brittle diabetes diagnosed?

The frequency of brittle diabetes is very low: <3/1000 patients with type 1 diabetes. Most cases are seen in adolescents and young adults (under 30 years old), with a second, much smaller peak in the seventh decade of life, predominantly in women.

How it develops

This involves the following conditions:

• Absence of endogenous insulin reserve, identified by the absence of C-peptide, which makes any event exacerbate hyperglycemia;
• Insulin resistance (IR), with peripheral sites, especially subcutaneous IR, caused by abnormalities in the insulin absorption rate. This induces unpredictable levels of insulin and the possibility of either ketoacidosis or frequent and severe hypoglycemia. If the patient shows a reduced glycemic response compared to the high dose of subcutaneous insulin injected, but absorption is normal, then systemic IR is likely, caused by mechanisms such as circulating anti-insulin antibodies, anti-receptor antibodies, or post-receptor mechanisms;
• The psychological factor is highly probable if other factors are excluded, especially subcutaneous IR (generalized).

Psychiatric anomalies that can occur in unstable diabetes are common and are classified into three main categories:

1. Induced brittle diabetes by the patient without a clear reason for this behavior. Patients may induce hyperglycemia by missing insulin injections, diluting preparations, reducing doses, etc. or inducing hypoglycemia by injecting doses that are too high or by supplementing insulin between meals.
2. Manipulative behavior, which means inducing instability with a specific purpose: gaining more attention from parents, avoiding school, or avoiding difficult social situations.
3. Communication issues between patients and healthcare personnel: misunderstanding advice and instructions, difficulty processing information, and applying it practically.

What are the types of brittle diabetes?

Clinically, brittle diabetes can be split in three forms:

1. Recurrent ketoacidosis predominance;
2. Recurrent hypoglycemia predominance;
3. Mixed forms.

Diagnosis of True Brittle Diabetes

It is essential to bring the patient to a state of normal glycemia, with frequent blood sugar monitoring through precise insulin administration, using continuous subcutaneous infusion.

The diagnostic process of brittle diabetes involves several stages:

1. Patient evaluation in the hospital, aiming to identify the factors leading to instability and correct them.
2. Through appropriate investigations, the organic cause of instability can be detected in almost all cases:
   • Eliminate endocrine and infectious diseases;
   • Check the insulin therapy regimen;
   • Assess access to diabetes information and education;
   • Investigate family and social conditions;
   • Uncover causes that produce or favor recurrent hypoglycemia and ketoacidosis.

Hospitalization is mandatory to exclude therapeutic errors, whether voluntary or intentional. Hospitalization is also necessary to assess insulin sensitivity.

Quantifying glycemic instability through the determination of indices that must respond to:

• What is the variability of blood sugar depending on the rhythm of insulin injections, meals, and physical activity?
• What is the degree of blood sugar variability from one day to the next, under identical conditions of treatment, food, and exercise?

Mathematical index calculations require continuous, automated blood sugar recording (using glucose sensors), which cannot be extended beyond 72 hours, limiting the quantification of the disease instability.

The most frequently used indicators include:

• MAGE – generates a glucose profile and calculates the average and standard deviation; the blood glucose fluctuations between two consecutive points are considered only if they meet the standard deviation threshold. MAGE is the arithmetic average of these consecutive variations. If MAGE is between 67-82 mg/dl, the diabetes is stable; characteristic values of instability range between 100-200 mg/dl.
• Mean differences of glucose values – comparing glucose values over two consecutive days under the same therapeutic conditions; if the mean differences for the same hours between the first and second day exceed 100 mg/dl, instability is confirmed.
• Calculation of the M index proposed by Schlichtkrull (1965), comparing each glucose value from a daily profile to an optimal glucose level of 20 mg/dl.
• Standard deviation of the mean of a glucose profile – if this is greater than 60 mg/dl, it is an indication of brittle diabetes.
• Average glucose levels measured 80 minutes after breakfast.

Therapeutic Management

The major and frequently life-threatening risk is hypoglycemia. The therapeutic goal is to reduce the frequency and severity of hypoglycemic episodes.

To ensure acceptable living conditions, the following measures should be individualized:

Potentially curative measures include:

• Hypoadrenalism
• Celiac disease
• Eating behavior disorders

Psychosocial measures:

• Psychiatric surveillance and psychotherapy
• Cognitive-behavioral therapy
• Optimizing lifestyle
• Insulin pump
• Continuous intraperitoneal insulin infusion
• Pancreas transplant
• Frequent self-monitoring of blood glucose
• Adherence to meal schedules
• Correctly rationalized physical activity

Complications

Chronic instability in blood glucose levels can lead to severe complications:

• Diabetic Ketoacidosis (DKA): Frequent hyperglycemia can result in DKA, a life-threatening condition where the body produces excess blood acids (ketones).
• Hypoglycemic Unawareness: Repeated episodes of hypoglycemia can desensitize the body, making it difficult to recognize low blood sugar symptoms, increasing the risk of severe hypoglycemia.
• Microvascular Complications: Prolonged periods of uncontrolled blood sugar can damage small blood vessels, leading to retinopathy, nephropathy, and neuropathy.

Living with brittle diabetes

Managing brittle diabetes can be challenging, but with the right strategies and support, individuals can lead fulfilling lives:

• Regular medical follow-ups: Maintaining consistent communication with healthcare providers to monitor progress and make necessary adjustments to treatment plans. Regular check-ups with an endocrinologist, diabetes educator, and dietitian can help ensure optimal management.
• Building a strong support system: Diabetes can be overwhelming, and brittle diabetes even more so. Connecting with family, friends, or diabetes support groups can provide emotional and practical support. Online forums and local diabetes organizations can also be valuable resources.
• Technology-assisted diabetes care: Leveraging diabetes management technology, such as insulin pumps, continuous glucose monitors (CGMs), and smartphone apps for tracking food intake and physical activity, can make blood sugar control more precise and predictable.
• Managing stress and mental health: Since stress plays a significant role in blood sugar fluctuations, practicing relaxation techniques such as mindfulness, yoga, deep breathing exercises, or engaging in hobbies can help manage stress levels. Professional therapy or counseling may also be beneficial for those struggling with anxiety or depression related to their diabetes.
• Emergency preparedness: People with brittle diabetes should always have a plan for handling severe hypoglycemia or hyperglycemia. Carrying fast-acting glucose sources, wearing a medical alert bracelet, and informing close friends and family about emergency protocols can prevent dangerous situations.

FAQs about brittle diabetes

1. Is brittle diabetes different from regular type 1 diabetes?

Yes, brittle diabetes is a severe and unstable form of type 1 diabetes characterized by extreme blood sugar fluctuations that are difficult to control, often requiring frequent hospitalization.

2. Can brittle diabetes be cured?

There is currently no cure for brittle diabetes, but with proper management, many people can significantly reduce blood sugar swings and improve their quality of life. In some cases, pancreas or islet cell transplantation may help restore insulin production.

3. What foods should I eat to help manage brittle diabetes?

A diet focused on whole, unprocessed foods with consistent carbohydrate intake, high fiber, and lean proteins can help stabilize blood sugar levels. Foods with a low glycemic index, such as leafy greens, nuts, and whole grains, may be particularly beneficial.

4. Can stress make brittle diabetes worse?

Yes, stress triggers the release of hormones like cortisol and adrenaline, which can cause blood sugar levels to spike or drop unpredictably. Learning stress management techniques can help improve blood sugar stability.

5. Is insulin pump therapy better for brittle diabetes?

For many individuals, an insulin pump combined with continuous glucose monitoring (CGM) can provide more precise insulin delivery and reduce the severity of blood sugar swings. However, treatment should be personalized based on each patient’s needs.

Brittle diabetes presents unique challenges, but with advancements in diabetes care, technology, and holistic management approaches, it is possible to gain better control over blood sugar fluctuations. Patients should work closely with healthcare providers to develop a personalized management plan, prioritize mental and emotional well-being, and adopt a proactive approach to self-care. By integrating medical support, lifestyle modifications, and psychological resilience, individuals with brittle diabetes can lead healthier and more stable lives. You should always consult with your doctor for the best strategy to apply. Managing diabetes is a 24/7 job with unique differences in each patient. Normal blood sugar everyone!