The adult patient with brittle diabetes mellitus
- David K McCulloch, MD
David K McCulloch, MD
- Washington Permanente Medical Group
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.
The clinical manifestations, diagnosis, and management of brittle diabetes will be reviewed here. General principles of insulin therapy in diabetes mellitus are reviewed elsewhere. (See "General principles of insulin therapy in diabetes mellitus" and "Management of blood glucose in adults with type 1 diabetes mellitus" and "Insulin therapy in type 2 diabetes mellitus".)
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). Thus, brittle diabetic patients virtually always have type 1 diabetes.
The majority of the published clinical literature regarding brittle diabetes is old with few modern-day descriptions of brittle diabetes encompassing the era of intensive insulin therapy [2,3]. With the availability of basal and bolus insulin regimens, using long and rapid-acting insulin analogs or insulin pump therapy, there has been substantial improvement in the ability to treat most patients with type 1 diabetes effectively . Although most clinical experts in the management of type 1 diabetes continue to see patients with brittle diabetes mellitus, many of whom have a substantial behavioral or iatrogenic contribution to their brittle state, the modern-day course of such patients has not been well described.
Three clinical presentations of brittle diabetes have been described: (1) predominant hyperglycemia with recurrent ketoacidosis, (2) predominant hypoglycemia, and (3) mixed hyper- and hypoglycemia . Frequent hypoglycemia, even if asymptomatic, causes both defective glucose counterregulation and hypoglycemia unawareness and, thus, a vicious cycle of recurrent hypoglycemia. (See "Physiologic response to hypoglycemia in normal subjects and patients with diabetes mellitus", section on 'Hypoglycemia-associated autonomic failure'.)
Subscribers log in hereLiterature review current through: Jul 2017. | This topic last updated: May 09, 2017.References
- Tattersall R, Gregory R, Selby C, et al. Course of brittle diabetes: 12 year follow up. BMJ 1991; 302:1240.
- Cartwright A, Wallymahmed M, Macfarlane IA, et al. The outcome of brittle type 1 diabetes--a 20 year study. QJM 2011; 104:575.
- Bertuzzi F, Verzaro R, Provenzano V, Ricordi C. Brittle type 1 diabetes mellitus. Curr Med Chem 2007; 14:1739.
- Vantyghem MC, Press M. Management strategies for brittle diabetes. Ann Endocrinol (Paris) 2006; 67:287.
- Schade DS, Drumm DA, Duckworth WC, Eaton RP. The etiology of incapacitating, brittle diabetes. Diabetes Care 1985; 8:12.
- Benbow SJ, Walsh A, Gill GV. Brittle diabetes in the elderly. J R Soc Med 2001; 94:578.
- Schade DS, Burge MR. Brittle diabetes: etiology and treatment. Adv Endocrinol Metab 1995; 6:289.
- Kent LA, Gill GV, Williams G. Mortality and outcome of patients with brittle diabetes and recurrent ketoacidosis. Lancet 1994; 344:778.
- Pickup J, Williams G, Johns P, Keen H. Clinical features of brittle diabetic patients unresponsive to optimized subcutaneous insulin therapy (continuous subcutaneous insulin infusion). Diabetes Care 1983; 6:279.
- Service FJ. Normalization of plasma glucose of unstable diabetes: studies under ambulatory, fed conditions with pumped intravenous insulin. J Lab Clin Med 1978; 91:480.
- Schade DS, Eaton RP. Intraperitoneal insulin administration in brittle diabetes. In: Brittle Diabetes, Pichup JC (Ed), Blackwell, Oxford 1985. p.275.
- Gill GV, Husband DJ, Wright PD, et al. The management of severe brittle diabetes with "Infusaid" implantable pumps. Diabetes Res 1986; 3:135.
- Connor H, Atkin G, Attwood E. Short-term control of brittle diabetes using a Biostator. Br Med J (Clin Res Ed) 1982; 285:1316.
- Gill GV, Lucas S, Kent LA. Prevalence and characteristics of brittle diabetes in Britain. QJM 1996; 89:839.
- Schade DS, Drumm DA, Eaton RP, Sterling WA. Factitious brittle diabetes mellitus. Am J Med 1985; 78:777.
- Schade DS, Eaton RP, Drumm DA, Duckworth WC. A clinical algorithm to determine the etiology of brittle diabetes. Diabetes Care 1985; 8:5.
- Hardy KJ, Burge MR, Boyle PJ, Scarpello JH. A treatable cause of recurrent severe hypoglycemia. Diabetes Care 1994; 17:722.
- Lehmann R, Honegger RA, Feinle C, et al. Glucose control is not improved by accelerating gastric emptying in patients with type 1 diabetes mellitus and gastroparesis. a pilot study with cisapride as a model drug. Exp Clin Endocrinol Diabetes 2003; 111:255.
- Moran G, Fonagy P, Kurtz A, et al. A controlled study of psychoanalytic treatment of brittle diabetes. J Am Acad Child Adolesc Psychiatry 1991; 30:926.