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Managing Brittle Diabetes

Management Strategies For Brittle Diabetes - Sciencedirect

Management Strategies For Brittle Diabetes - Sciencedirect

Volume 67, Issue 4 , September 2006, Pages 287-294 Management strategies for brittle diabetesStratgies de prise en charge du diabte instable Author links open overlay panel M.-C.Vantyghem1 Get rights and content Type 1 diabetes is an intrinsically unstable condition. However, the term brittle diabetes is reserved for those cases in which the instability, whatever its cause, results in disruption of life and often recurrent and/or prolonged hospitalization. It affects 3/1000 insulin-dependent diabetic patients, mainly young women. Its prognosis is poor with lower quality of life scores, more microvascular and pregnancy complications and shortened life expectancy. Three forms have been described: recurrent diabetic ketoacidosis, predominant hypoglycemic forms and mixed instability. Main causes of brittleness include malabsorption, certain drugs (alcohol, antipsychotics), defective insulin absorption or degradation, defect of hyperglycemic hormones especially glucocorticoid and glucagon, and above all delayed gastric emptying as a result of autonomic neuropathy. Psychosocial factors are very important and factitious brittleness may lead to a self-perpetuating condition. The assessment of brittle diabetes requires quantification of the variability of blood glucose levels. To quantify instability, measures which have been developed, include Mean Amplitude of the largest Glycemic Excursions (MAGE), Mean Of Daily Differences (MODD), Lability Index (LI), Low Blood Glucose Index (LBGI), Clarke's score, Hyposcore, and continuous blood glucose monitoring. Once psychogenic problems have been excluded, therapeutic strategies require firstly, the treatment of underlying organic causes of the brittleness whenever possible and secondly optimising standard insulin therapy using analogu Continue reading >>

Brittle Diabetes: As Knowledge Advances, Aging Term Loses Favor

Brittle Diabetes: As Knowledge Advances, Aging Term Loses Favor

Brittle Diabetes, a term coined in the 1940s, is considered an antiquated term. As knowledge and technology have advanced, clinicians now recognize that widely variable fluctuations in glucose levels ultimately have an underlying cause. Although, there are still some cases that are more challenging and difficult to manage. As noted, prognosis is poor in patients with “brittle diabetes.” They tend to have lower QOL scores, more microvascular complications, and shortened life expectancies. Three forms have been described: recurrent diabetic ketoacidosis, predominant hypoglycemic forms, and mixed instability. The assessment of brittle diabetes requires quantification of the variability of blood glucose levels. Multiple measuring systems are available to quantify instability, including Mean of Daily Differences (MODD), Mean Amplitude of the largest Glycemic Excursions (MAGE), and Lability Index (LI). Currently, healthcare providers prefer terms such as labile diabetes, glucose variability, or uncontrolled diabetes over the term brittle diabetes. Contributing factors can take investigational work on the provider’s part and often more time than the typical 20-minute appointment. Moreover, the cause can vary from patient to patient. Common etiologies include: inconsistencies in diet and physical activity, psychosocial, medication adherence, proper administration, overcorrection of hypo/hyperglycemia, adherence to self glucose monitoring, asymptomatic hypoglycemia, and other conditions such as depression, alcohol abuse, renal disease, and gastroparesis. Uncovering and treating the cause is the key. Asymptomatic hypoglycemia, a common cause of high glucose variability, can cause resultant hyperglycemia from exaggerated overcorrection upon detection of hypoglycemia. One sol Continue reading >>

Is Brittle Diabetes Real?

Is Brittle Diabetes Real?

If youve lived on this planet for a certain amount of time, you may be familiar with the term brittle diabetes usually used to describe unstable, difficult-to-treat Type 1 diabetes . According to a recent piece on MedPage Today , in recent decades, this term has fallen out of favor, just as many experts believe that actual instances of what the term describes have fallen, as well. So was brittle diabetes just a convenient label for doctors who didnt know how to adequately control certain cases of diabetes in the past? Or is there something real to the phenomenon? Two studies published in recent years may help shine some light on the answer. One study , published last year in the Journal of Diabetes Research, was a case study of an adolescent girl with Type 1 diabetes and how her blood glucose levels corresponded to family dynamics and moods. Using complex statistical modeling, the researchers came up with a model with 70 parameters that explained the relationship between the moods of all family members and the girls blood glucose variability. For example, they found that a period of high blood glucose variability correlates with an excited mother seven days earlier, a dominating mother four days earlier, and a dominating father both two and five days earlier, based on self-reported scores of their moods that all family members kept. The researchers concluded that theres most likely a two-way relationship between psychological factors, like the mood of someone with diabetes or her family members, and blood glucose control. This may be especially important for adolescents to know, since according to one estimate, just 33% of people ages 1319 with diabetes maintain tolerable glycemic control, with an HbA1c level (a measure of long-term blood glucose control) below 8%. In Continue reading >>

Brittle Diabetes: A Real Issue Or A Lack Of Knowledge?

Brittle Diabetes: A Real Issue Or A Lack Of Knowledge?

Brittle diabetes is a term used for those with type 1 diabetes who feel that no matter what they do, their blood sugars are all over the map. Swinging extremely high and extremely low, without any predictability or stability or “control.” But if you’ve lived with type 1 diabetes long enough–in a world where you’re expected to control something in your body that it is supposed to control itself…that is affected by 5-dozen variables both internal and external–then you know just how complicated real diabetes management is. For this reason, it is very likely that some of you who feel you have “brittle diabetes” may actually just be missing some key knowledge and education on how many different variables impact your blood sugar and your insulin needs. And it’s no fault of your own: type 1 diabetes is a never-ending learning process. If you think you’ve learned everything there is to know about type 1 diabetes, then it’s very likely you have a lot left to learn. Some of the most successful type 1 diabetic athletes, for example, consistently say the same thing: I am constantly learning about my diabetes. So: how do you know if you have brittle diabetes or if it’s time to really learn more about your body as a person with diabetes? Gary Scheiner, CDE, type 1 diabetic and author of the award-winning (and must-have for any type 1) book, “Think Like a Pancreas,” shared with me a few key points when it comes to the ever questionable “brittle diabetes.” “It is true that some people are more prone to rapid, extreme (and sometimes unexplainable) glucose swings than others,” explains Scheiner. “These tend to be people whose beta-cell function, as measured by c-peptide, is virtually non-existent. However, most type-1s, even those with long-standin Continue reading >>

Brittle Diabetes Management

Brittle Diabetes Management

The assumption generally made is that exercise will serve to decrease blood glucose (BG) levels . Brittle diabetics need to be aware that sugar levels can go in either direction, up or down, during and following aworkout. This complicates matters for a brittle person who never really knows which direction their bloodglucose is heading . This requires careful and continuous monitoring on their part to ensure a margin of safetywhile working out. As a result, a series of general guidelines have been recommended for Type 1 diabetics by health careprofessionals : You should always discuss with your doctor and members of your health care team a plan for developing an exercise program suited to your condition. Since each persons diabetic response is individualized, an exercise program should be customized to prevent worsening any problems you may already have. Ask your doctor to recommend the best type, time and level of exercise you should engage in. By trial and error you will eventually adjust to a regimen that is specific to your bodys response pattern. Drink water to hydrate the body recommendation: 16 oz. 2 hours before, 8 oz. hour before and 4 to 6 oz. every 15 minutes while exercising. Monitor BG before, during and after exercising. If your BG level is between 100 and 250mg/dL prior to exercising, it is generally considered safe to beginyour workout routine. If below 100mg/dL, the recommendation is to eat a carbohydrate rich snack (15 to 30 gr) prior to beginning the exercise program. If between 250 and 300mg/dL , be sure to test for ketones in your urine. If positive , dont exercise otherwise you risk DKA. Postpone until ketones decline to normal levels. If negative , begin exercising but be sure to test 10 minutes after the start to determine BG levels. If rising st Continue reading >>

Brittle Diabetes (labile Diabetes)

Brittle Diabetes (labile Diabetes)

Tweet Brittle diabetes mellitus (or labile diabetes) is a term used to describe particularly hard to control type 1 diabetes. Those people who have brittle diabetes will experience frequent, extreme swings in blood glucose levels, causing hyperglycemia or hypoglycemia. How does brittle diabetes develop and what is it associated with? Brittle diabetes has a number of potential causes. It can be caused by absorption problems in the intestines. This includes delayed stomach emptying, drug interactions, insulin absorption issues and malfunctioning hormones. Severely low blood sugar levels may also create thyroid and adrenal gland problems. Gastroperesis, delayed stomach emptying, can affect the rate at which food, glucose and insulin is absorbed into the bloodstream. Brittle diabetes is often associated with psychological issues such as stress and depression. Is brittle diabetes different from stable diabetes? All people with diabetes will a certain level of blood glucose level fluctuation. However, when these shifts are not extreme or over-frequent they do not impair the ability to lead a normal life. With brittle diabetes, however, the fluctuations are more serious and tend to result in frequent hospital visits, interruption to employment and can often contribute to psychological issues such as stress. Life expectancy with brittle diabetes The life expectancy for someone with brittle diabetes is no different to someone who has type 1 or type 2 diabetes. In fact, brittle diabetes can also be described poorly controlled type 2 diabetes. Is brittle diabetes common? Brittle diabetes is rare but serious. Around 3 in 1,000 people with type 1 diabetes mellitus will develop brittle diabetes. Will I get brittle diabetes? Those people suffering from psychological problems, includin Continue reading >>

Brittle Diabetes May Be A Sign Of Psychiatric, Organic Illness

Brittle Diabetes May Be A Sign Of Psychiatric, Organic Illness

Brittle Diabetes May Be a Sign Of Psychiatric, Organic Illness NEW YORK True brittle diabetes is a rarity, with characteristic blood glucose lability, frequent hospitalizations, and life disruption often reflecting underlying psychiatric or organic disease, according to Dr. Irl B. Hirsch. Diagnosis and management of this potentially lethal condition present significant challenges, as was shown in several cases Dr. Hirsch presented at a meeting sponsored by the American Diabetes Association. One case involved a 23-year-old woman who presented with a 15-year history of type 1 diabetes in 2000. She had been on an insulin pump for 5 years, and her hemoglobin A1c (HbA1c) levels ranged from 9% to 12%. As a teenager she had had an eating disorder and had multiple hospitalizations for diabetic ketoacidosis. In the previous 2 years she had been hospitalized twice for gastroparesis, and had developed severe peripheral neuropathy and osteoporosis. By 2002 she developed nonproliferative retinopathy and proteinuria. All those years of poor control were already catching up with her at age 25, said Dr. Hirsch, professor of medicine in the division of metabolism, endocrinology, and nutrition at the University of Washington, Seattle. In 2004 she had an unplanned pregnancy and was hospitalized for 4 months, delivering the child 3 months prematurely. Her glucose was well controlled while she was in the hospital, but subsequently HbA1c became elevated once again, reaching 10.4%. Finally, in the summer of 2006, she had a kidney-pancreas transplant. So the question is, does she have brittle diabetes? Dr. Hirsch asked. A diagnostic work-up determined that she had underlying celiac disease, with an important clue being the osteoporosis. When you see osteoporosis in a young person you have to Continue reading >>

The Adult Patient With Brittle Diabetes Mellitus

The Adult Patient With Brittle Diabetes Mellitus

INTRODUCTION 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) [1], 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".) CLINICAL MANIFESTATIONS 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 [3]. Although most clin Continue reading >>

Management Strategies For Brittle Diabetes.

Management Strategies For Brittle Diabetes.

Abstract Type 1 diabetes is an intrinsically unstable condition. However, the term "brittle diabetes" is reserved for those cases in which the instability, whatever its cause, results in disruption of life and often recurrent and/or prolonged hospitalization. It affects 3/1000 insulin-dependent diabetic patients, mainly young women. Its prognosis is poor with lower quality of life scores, more microvascular and pregnancy complications and shortened life expectancy. Three forms have been described: recurrent diabetic ketoacidosis, predominant hypoglycemic forms and mixed instability. Main causes of brittleness include malabsorption, certain drugs (alcohol, antipsychotics), defective insulin absorption or degradation, defect of hyperglycemic hormones especially glucocorticoid and glucagon, and above all delayed gastric emptying as a result of autonomic neuropathy. Psychosocial factors are very important and factitious brittleness may lead to a self-perpetuating condition. The assessment of brittle diabetes requires quantification of the variability of blood glucose levels. To quantify instability, measures which have been developed, include Mean Amplitude of the largest Glycemic Excursions (MAGE), Mean Of Daily Differences (MODD), Lability Index (LI), Low Blood Glucose Index (LBGI), Clarke's score, Hyposcore, and continuous blood glucose monitoring. Once psychogenic problems have been excluded, therapeutic strategies require firstly, the treatment of underlying organic causes of the brittleness whenever possible and secondly optimising standard insulin therapy using analogues, multiple injections and consideration of Continuous Subcutaneous Insulin Infusion. Alternative approaches may still be needed for the most severely affected patients. Isolated islet transplantation Continue reading >>

Managing Diabetes: Challenging Or Impossible?

Managing Diabetes: Challenging Or Impossible?

Managing diabetes: challenging or impossible? Volatile blood-sugar swings should be checked by a specialist Living with type 1 diabetes (T1D) has physical, emotional and psychological challenges. People with the disease must carefully balance insulin doses with food consumption and physical activity. They must measure their blood glucose by pricking their fingers for blood six or more times a day and also cope with the constant worry and attention that diabetes requires. Even with all of these efforts, people with T1D must also accept that every day something will not go as planned. Living with diabetes is dangerous! People with T1D run the risk of high or low blood-glucose levels daily, both of which can be life threatening. This disease is terrifying for families, loved ones and individuals living with T1D. Nicole Johnson, Dr.P.H., M.P.H., M.A., a member of the JDRF International Board of Directors and Miss America 1999 Managing diabetes is tough for everyone. But for some people it is especially hard. No matter how diligently they care for themselves, their blood-sugar levels change erratically, spiking high enough to cause ketoacidosis or plunging dangerously low with little warning. The rapid and unpredictable blood-sugar fluctuations are so extreme they interrupt regular daily activities and increase risk for debilitating complications and acute medical emergencies. When the challenge of managing diabetes becomes an impossible one, it can be a sign that there are other health issues that need to be addressed. This is sometimes called brittle diabetes. In brittle diabetes, many factors may contribute to turbulence in blood-glucose levels, according to the Genetic and Rare Diseases Information Center of the National Institutes of Health. Conditions that can cause t Continue reading >>

Management Strategies For Brittle Diabetes - Em|consulte

Management Strategies For Brittle Diabetes - Em|consulte

Management strategies for brittle diabetes [1]Endocrinology and Metabolism Department, Lille University Hospital, France. [2]Department of Endocrinology, Royal Free Hospital, London NW3 2QG, UK. [3]Endocrinology and Metabolism Department/ERIT-M0106, 6 Rue du Pr Laguesse, 59037 Lille Cedex. Stratgies de prise en charge du diabte instable Le diabte de type 1 est une situation instable en elle-mme. Cependant le terme de diabte instable est rserv aux cas dans lesquels linstabilit quelle quen soit la cause entrane une dsorganisation de la vie du patient avec hospitalisations rcurrentes ou prolonges. Le diabte instable touche ainsi 3/1000 patients diabtiques insulino-dpendants, essentiellement des jeunes femmes. Son pronostic, mdiocre, sassocie des scores de qualit de vie faibles, des complications microvasculaires et prinatales plus frquentes et une diminution de lesprance de vie. Trois formes ont t dcrites: la ctoacidose rcurrente, les formes prdominance hypoglycmique et les formes mixtes. Les principales causes dinstabilit correspondent aux malabsorptions, la prise de certaines drogues (alcool, antipsychotiques), aux dfauts dabsorption ou de dgradation de linsuline, aux dfauts de scrtion des hormones de contre-rgulation, notamment les glucocorticoides et le glucagon, et par dessus tout aux troubles de la vidange gastrique secondaires une neuropathie autonome. Les facteurs psychosociaux sont trs importants et linstabilit factice peut entretenir une situation. Lvaluation dun diabte instable requiert une apprciation de la variabilit des glycmies. Afin de quantifier cette instabilit, diffrents outils de mesure ont t dvelopps, parmi lesquels lamplitude moyenne des plus grandes excursions glycmiques (MAGE), la moyenne des differences quotidiennes (MODD), lindice de labilit (LI) Continue reading >>

What To Do About Brittle Diabetes

What To Do About Brittle Diabetes

Q: I am a brittle diabetic and live in fear every day as my blood sugar goes from high to very low within a few hours, and I never know it’s low until it is too late. I understand there’s a new oral drug for this, and I hope you can share some information with me. Also, I’d like to know what’s new in terms of a cure-I hear rumors, but never see the new techniques or good news in doctor’s offices. Please share any news of new treatment. A. M. Craft Ashland, KY A: You have really asked three good questions, and I will address them separately. 1. You are very correct to be concerned about the very low blood sugars, especially if you can’t sense it until it is “too late.” It is very important that you review this with your doctor, and a change in insulin regimen be made. “Hypoglycemia unawareness” is not rare, and is generally treated by allowing the blood sugars to rise high enough that the low blood sugars are eliminated. One then seeks to attain a more stable or predictable level of control of higher blood sugars, and then slowly bring them down. Causes of unexplained hypoglycemia include life-style problems (unexpected stresses, erratic food habits, etc.), gastroparesis (slow and unpredictable emptying of food from the stomach), erratic insulin absorption from injection sites (especially if there is a buildup or breakdown of fat below the skin), and other factors. All of these should be reviewed with your doctor. For erratic life-style issues, a more structured program is helpful. For gastroparesis, medications such as Reglan, Motilin, or Cisapride may be effective, as may having some liquid portion at each meal. Remember that fat tends to be released from the stomach more slowly in all people. For areas of abnormal fat buildup or breakdown under the Continue reading >>

What Is Brittle Diabetes?

What Is Brittle Diabetes?

Note: This article is part of our library of resources for Forms of Diabetes. Brittle diabetes is a rare form of insulin-dependent diabetes and is marked by frequent and severe episodes of hypoglycemia and/or hyperglycemia (DKA). This instability of blood sugar levels often leads to hospitalization and necessitates frequent self-monitoring of blood glucose, the use of an insulin pump and a continuous glucose monitoring device (CGM). In rare cases, a pancreas transplant may be necessary. What causes Brittle diabetes? There can be many causes of Brittle diabetes, but here are some of the most frequent ones (NIH): Emotional stress Hormonal imbalance Poor personal care Malabsorption (when your small intestine cannot absorb nutrients from foods) Autonomic neuropathy complications (such as delayed gastric emptying) Celiac disease Hypothyroidism Adrenal insufficiency systemic insulin resistance abnormal insulin absorption Impaired glucose counter-regulation (the patient’s body doesn’t react predictably when blood glucose levels drop) Drug or alcohol use Who does it affect? Brittle diabetes primarily affects those with Type 1 diabetes and is most common in women in their 20s and 30s, but can occur in men as well and at any age. It affects 3/1000 insulin-dependent individuals (NCBI). Continue reading >>

What Is Brittle Diabetes?

What Is Brittle Diabetes?

Brittle diabetes is a severe form of diabetes. Also called labile diabetes, this condition causes unpredictable swings in blood sugar (glucose) levels. These swings can affect your quality of life and even lead to hospitalization. Thanks to advances in diabetes management, this condition is uncommon. However, it can still occur in people with diabetes. In some cases, it’s a sign that your blood sugar is poorly managed. The best way to prevent brittle diabetes is to follow a diabetes care plan created by your doctor. The biggest risk factor for brittle diabetes is having type 1 diabetes. Brittle diabetes occurs mainly in people with type 1 diabetes, and rarely in people with type 2 diabetes. Some doctors classify it as a complication of diabetes, while others consider it a subtype of type 1 diabetes. Type 1 diabetes is characterized by high blood sugar levels (hyperglycemia). However, your body may have a reaction to insulin, also causing dips in glucose levels. This results in a dangerous “roller coaster” effect. The fluctuation in glucose levels can be rapid and unpredictable, causing dramatic symptoms. In addition to having type 1 diabetes, your risk of brittle diabetes is higher if you: are female have hormonal imbalances are overweight have hypothyroidism (low thyroid) are in your 20s or 30s have a high level of stress on a regular basis have depression Frequent symptoms of low or high blood glucose levels are common indicators of brittle diabetes. People with type 1 or type 2 diabetes can experience these symptoms when their blood sugar levels are off. However, with brittle diabetes, these symptoms occur and change frequently and without warning. Symptoms of very low blood sugar levels include: dizziness weakness irritability extreme hunger trembling hands do Continue reading >>

What Is Brittle Diabetes?

What Is Brittle Diabetes?

Brittle diabetes, also called labile diabetes, is a term used to describe hard-to-control type 1 diabetes. People with brittle diabetes frequently experience large swings in blood sugar (glucose) levels which can quickly move from too high (hyperglycemia) to too low (hypoglycemia) or vice versa. . Other Conditions Related to Brittle Diabetes Brittle diabetes can be caused by emotional distress (including depression and stress), eating disorders,gastrointestinal absorption problems, including delayed stomach emptying (gastroparesis), Celiac disease, 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 may lead to the resolution of 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 andunlike brittle diabetesdo not impact the ability to carry out regular activities of daily living. Brittle diabetes is relatively rare.According to the National Institute of Health (NIH),only a small proportion of people with type 1 diabetes experience the frequent blood glucose swings described as brittle.It affects approximately 3/1000 insulin-dependent people with diabetes, mainly 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. Additionally, 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 e Continue reading >>

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