Brittle Diabetes

Case Study

A few years ago, a middle-aged well dressed, and educated gentleman Mr. Alok Mehta (name changed) 60+ visited my diabetes clinic at CR Park in south Delhi. He started, "Doctor Sometimes, my blood sugars drop as low as 45 and then shoot up to the 300s during a day. Though I am not able to comprehend, the reasons what I feel are that my insulin dosing is not right, or I make carb counting mistakes, or maybe due to some recent family stress( his wife died of cancer recently) or simply laziness on my part…Can you help me out ?"

He continued further, "My blood sugars can shift up or down many times in a day by as much as 260 points in less than an hour. Apart from feeling ill, there are a few other symptoms such as perspiration, tremors, irritability, loss of cognitive function, and slurred speech during these rapid shifts. That’s just my life with diabetes on certain days".

I am a widower and live alone, my kids are settled abroad and I get quite worried at night because of the hypos and am tired of checking my blood sugars again and again and not getting proper sleep. I don't know what to do?

Brittle diabetes- fluctuations in blood sugar levels (CGMS)

What is Brittle diabetes?

Nearly all people with diabetes may have occasional see-saw patterns in blood sugar. But, there is a small (less than 1% ) group of diabetic patients, whose lives are daily disturbed by constant fluctuations of blood glucose, that is severe and unpredictable. One moment it is fine and in the next, it jumps or drops to another level. It seems like their blood sugar levels are riding on a roller coaster. They are the people with brittle (or labile) diabetes, a type of hard-to-control diabetes, which shows wide glycemic variability between too high (hyperglycemia) and too low (hypoglycemia) blood glucose levels.

Brittle Diabetes- How common it is?

Brittle diabetes is quite rare, less than 1% of the insulin-dependent diabetic population suffers from it. It is usually seen in young & old patients with Type 1 diabetes, which is an unstable condition. In others, it is present in Type 2 diabetic persons who are quite high in their diabetic age ( years of diabetes, not actual age), so the patient is typically over 60, has exhausted their pancreatic beta-cell mass, and are now practically insulin-dependent. Hence, some diabetes specialists regard brittle diabetes to be a subtype of type 1 diabetes. Other diabetologists, consider it to be a complication of Type 2 diabetes. Either way, it is relatively rare.

Why it is problematic?

Brittle diabetes typically refers to those cases in which the wide fluctuations in blood sugar levels disrupt the quality of life. The main reasons to consider it a major burden of healthcare by diabetes doctors are:

1. Diabetic complications due to damage of small blood vessels and nerves, like neuropathy, nephropathy & retinopathy, and even atherosclerotic disease.

2. It may lead to frequent, multiple, and expensive hospitalizations and contribute to a financial burden.

3. Massive stress leading to insomnia.

4. Diabetic ketoacidosis

5. Shortened life expectancy.

Who are at risk?

Most patients with brittle diabetes have wide fluctuations of blood glucose levels, even in response to the same dose and type of insulin. Research shows that it can occur in

1. Prolonged type 2 diabetic patients ( diabetic age over 20 years or more)

2. Few studies have shown it to be more common in women, but others suggest that it can affect both men and women and of any age.

3. Type 1 diabetic patient are at the maximum risk.

What are the signs & symptoms?

The signs and symptoms of brittle diabetes vary from patient to patient, although in most cases it remains constant for an individual. The symptoms can range from

• loss of balance & coordination

• impaired memory or intellectual function,

• confusion & impaired judgment

• inability to concentrate

• insomnia

• blurring of vision

• frequent urination

• sweating,

• anxiety,

• tremor,

• frequent hunger pangs

• palpitations.

What can happen if your blood sugar gets too low?

Most people with brittle diabetes learn to recognize and take some preventive action upon the warning signs of hypoglycemia. But in others, these symptoms are silent Or they do not identify that their blood sugar has dropped very low. This event is known as ‘hypoglycemia unawareness’—a unique feature of brittle diabetes. This can occur because of patients' knowledge, symptoms overlapping with some other co-morbid conditions, and sometimes few medications which can mask the warning signals of hypoglycemia.

Unless treated by immediate ingestion /infusion of glucose, patients can lose consciousness, what is called ‘hypoglycaemic coma’. Left untreated, if the coma may last for several hours it can even be fatal.

HYPOGLYCEMIA V/S HYPERGLYCEMIA- SYMPTOMS

What can happen if your blood sugar gets too high?

A very serious condition associated with brittle diabetes is known as recurrent diabetic ketoacidosis or DKA. This usually happens when there is a lack of insulin to utilize glucose for energy, it starts to burn down fat and subsequently muscle stores for energy. This process leads to a build-up of metabolic waste, called ketones, in blood and urine. Symptoms of ketoacidosis include nausea, vomiting, pain in the abdomen, palpitations, excessive thirst, frequent urination, breathlessness, the fruity smell in breath, and confusion. Timely intervention, if not available, then ketoacidosis can be fatal.

What leads to Brittle diabetes?

1. Insulin is vital for people with type 1 diabetes. It is required to maintain a normal concentration of sugar in the blood. In patients with T1DM insulin therapy is based on multiple daily injections (BASAL-BOLUS REGIMEN) or continuous pump-regulated infusion. No matter which regimen we follow, the most common side-effect of insulin-based treatment is the risk of hypoglycemia.

2. Other factors that can trigger frequent alterations in blood glucose levels are:

A. inconsistencies in diet,

B. medication compliance

C. PCOS and hormonal imbalances

D. Obesity & overweight

E. hypothyroidism (or low thyroid hormones)

3. Malabsorption syndromes:

A.Diabetic gastroparesis is a condition when the stomach cannot empty itself of food in a normal fashion.

B. Celiac disease is an immune reaction to gluten (in wheat and other gluten-rich products) that creates severe internal inflammation, damages the small intestine endothelial lining, and leads to medical complications.

C. Other Gastrointestinal disorders, such as inconsistent digestion, diarrhea, constipation, incontinence, difficulty in swallowing, gastroparesis, non-alcoholic fatty liver disease (NAFLD), gastro-esophageal reflux disease (GERD)

4. Alcohol & certain drugs, like beta-blockers and thiazide diuretics, or antipsychotics,

5. Acute psychological stress, depression as well as schizoaffective or personality disorders can result in glycaemic instability by causing acute and temporary insulin resistance.

6. Diabetic autonomic neuropathy

7. Counterregulatory Hormones (increase blood glucose) include glucagon, cortisol, thyroxin, growth hormone, catecholamines like noradrenaline & dopamine, and ACTH. Improper secretion of these hormones, especially glucagon and glucocorticoids, can lead to Brittle diabetes

How to MANAGE BRITTLE DIABETES?

1. First, remember that Brittle Diabetes is complicated and not easy to manage. Don't try to manage it yourself. Take the help of the best diabetes doctors near you.

2. You will not achieve instantaneous results. Give time to your treating diabetologist.

3. Keeping diabetes under good control is a must To achieve that, assessment of our eating habits, physical activity, personal and family life, compliance with treatment, correct application of insulin, and its dosing is as important as other conditions like stress, depression, drinking problems.

4. A reduced carbohydrate diet is very helpful to reduce wide swings in blood glucose, take help of your diabetes specialist or nutrition expert

5. Closer monitoring with new technologies, such as CGMS (continuous glucose monitors system) and subcutaneous insulin pumps, are at the mainstay.

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6. Psychological issues if present, should be corrected first with counseling, cognitive and mindfulness-based therapies. These treatments have success in dealing with problems such as stress, anxiety, and depression.

7. Radical new treatments like pancreatic transplants, Stem cell therapy are emerging as the new frontier for managing brittle diabetes.

8. Maintain a healthy weight,

9. Widen your general diabetes knowledge,

10. Last but not least, working as a team with your endocrinologist (who treats diabetes and hormonal issues), dietician, and your family is the key to overcoming brittle diabetes.

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