What Is ‘Brittle’ Diabetes?

Brittle diabetes, also called labile diabetes, is a term used to describe uncontrolled type 1 diabetes. People with brittle diabetes frequently experience large swings in blood sugar (glucose) levels. These cause either hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar), which is more common and sometimes extreme.

Other Conditions Related to Brittle Diabetes

Brittle diabetes can be caused by gastrointestinal absorption problems, including delayed stomach emptying (gastroperesis), drug interactions, problems with insulin absorption, or hormonal malfunction.

People who have severely low blood sugar levels may also have problems with their thyroid (hypothyroidism) and adrenal glands (adrenal insufficiency).

Treatment of these conditions often leads to the resolution of brittle diabetes.

Gastroperesis can affect relative absorption rates of food, glucose and insulin into the bloodstream. The problem can be a side effect of damage to the nerves that control internal organs. This is a condition that sometimes occurs in people with diabetes. Medications such as Reglan (metoclopramide) do help to encourage more normal stomach emptying. Studies have found, though, that treating gastroperesis does not lead to improvements in overall control of the diabetes or its related complications.

Psychological problems, including depression and stress, are also often associated with brittle diabetes.

Difference between Brittle and Stable Diabetes

The blood sugar levels of people with stable diabetes may fluctuate occasionally. However, these fluctuations are not frequent and -- unlike brittle diabetes -- do not impact the ability to carry out regular activities of daily living.

Brittle Diabetes and the Family

The person with brittle diabetes is frequently hospitalized, misses work and often has to contend with psychological problems.
All of these factors place additional emotional and financial stress on family members.

How Often Does Brittle Diabetes Occur?

Brittle diabetes is relatively rare. Less than 1 of people who have insulin-dependent diabetes patients experience brittle diabetes. However, those who do are often troubled by frequent medical problems and hospital admissions.
Overall, three in 1,000 (0.3 of) people with type 1 diabetes will develop brittle diabetes.

Who Gets Brittle Diabetes and Why

People with psychological problems, such as stress and depression, are at highest risk of experiencing brittle diabetes. In some cases, these psychological problems lead them to neglect self-care for their diabetes. For example, they may stop maintaining a healthy diet or may not manage their blood sugar). As blood sugar control wanes, metabolic imbalances further complicate and often worsen the underlying psychological problems, causing a repetitive cycle of brittle diabetes.

One small study documented that people with brittle diabetes have a greater hormonal response to stress than those whose diabetes is not brittle. This psychological-hormonal connection may influence the development of brittle diabetes.

Brittle diabetes is more common in young women, with overweight women more likely to be affected. Most people with brittle diabetes tend to be between the ages of 15 and 30.

Treatment for Brittle Diabetes

Identifying and correcting the underlying issues, whether physiologic or psychological, is essential to treating brittle diabetes. Blood tests can help to determine the cause of glucose instability. If blood glucose responds normally to diabetes drugs in a controlled environment (such as in a hospitalized patient), then one should look for environmental, psychological or behavioral causes.

While there may be a physiological explanation for brittle diabetes, that's only one of the potential behavioral/environmental explanations, and diagnosing a psychological cause of brittle diabetes can often be a lengthy and challenging process.

If the cause is determined to be psychological, treatment may involve exploring and trying to lessen the stress of the person's situation. It is helpful to consult a psychology professional in evaluating and treating these patients. Psychotherapy has proven to be effective in treating brittle diabetes.

Patients 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.

Selected patients with severe degrees of brittle diabetes may consider isolated islet transplant or pancreas transplant.

While promising, transplantation remains a relatively new therapy and carries significant risks, including those associated with anti-rejection immunosuppressive therapy. Therefore, only people who have exhausted all other means of glucose management should consider transplantation.

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


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