Brittle Diabetes Update

Brittle diabetes update is possible thanks to Atlantic Health Sciences Corporation. UpToDate does a review of over 375 journals and other resources. This review is current through April 2007 and the next review will be released in October 2007 after which time, I will be at liberty to present it to you if people are interested in it.

And now for the brittle diabetes update, we will remind ourselves that diabetic patients go through extreme swings in blood sugar levels that are less predictable than in general population. The swings become so unbearable they disrupt the patient's life, depending on the mind, skill and confidence of both patient and doctor.

The brittle diabetes update of this patient with this condition is one whose life is persistently interrupted by incidents of hyperglycemia and hypoglycemia. These patients are rare in the sense that only less than 1% of those who take insulin are affected by it. However, due to frequent hospitalization, it takes a toll on the hospital and family resources.

Studies have been conducted that focus on the physiological aspect that tried different approaches in the delivery of insulin. The brittle diabetes update reports that they tried nonstop subcutaneous, intramuscular, intravenous infusion hoping one of these will solve the problem.


After so many studies, it was clear that most of the cases are due to psychological factors so they tried to approximate the number of brittle patients. In the UK, they sent a questionnaire to all diabetic clinics there and recognized 414 brittle patients, a prevalence of 2.9 per 1000 patients who were treated with insulin. The doctors felt 93% were due to psychological problems.

Tattersall et al followed up patients they identified who had three or more admissions for ketoacidotic brittleness in two years and those admitted for severe hypoglycemic brittleness in one year. They followed up these patients for twelve years and here are their findings:

  • The majority of the 25 patients were consistent in the sense that their incidents were either ketoacidotic or hypoglycemic type. Only five showed mixed brittleness. Similar findings were reported in the other studies.
  • The mortality rate was 20% (two from uremia, two from hypoglycemic coma and one from brain tumor).
  • The survivors did not show evidence of greater microvascular complications with about 10% still brittle.

The researchers believe that the brittleness was due to the patient's unhappy life. When the situation was resolved, the brittleness just stopped. It looked like the patients were using their brittleness as an escape mechanism from an unhappy situation.

There were two other studies from specialist centers that replicated the above findings. But there were differences in the sense that these studies reported more women, more microvascular and pregnancy complications. The insulin dose seemed to drop and the incidents of ketoacidosis and severe hypoglycemia became less often.

The recommendations as reported by the brittle diabetes update is that the approach to manage the cases will vary depending on the cause. A detailed history should be taken covering length of the disease, the episodes and the period of stability. Then it is good to determine what happened to the patient before the brittleness occurred.

A psychological evaluation is always necessary because psychotherapy has been shown to be helpful in some cases as the brittle diabetes update reveals. Especially it is a known fact that many patients will continue to have recurrent problems until their life situation is improved.

Those with repeated episodes of ketoacidosis should be checked for a possible persistent cryptic infection to exclude osteomyelitis, sinusitis, renal and lung abscess. These problems may be there for patients using intravenous drugs so a urinary drug screen may be helpful.

There might also be a difference between food and insulin absorption in which case stomach emptying studies may be helpful but the trouble is the Cisapride used in the situation has been severely restricted because it was implicated with some drug interaction and fatal cardiac problems.

Sometimes patients are unaware of hypoglycemia and these cases can result in more nasty episodes. Hypothyroidism and adrenal deficiency cause severe repeated hypoglycemia but once recognized these are easily treated as the brittle diabetes update reports.

Since about one-third of these cases are found to have communication problem as the main cause of the brittleness, treating this has been found to be of benefit to 75% of the cases. The diagnosis for the communication disorder can be made by speech language pathologists.

The hospital admission of severe cases can last two to three weeks. In the first week, the patient has to stay in the treatment unit where he can be observed and monitored with blood glucose testing, meal planning and insulin injection all done by the staff.

When the blood glucose control and behavior are acceptable then the patient may be permitted to be involved in the management of his disease during the last two weeks. For those who are manipulative and won't admit to having a psychological and communication problem, the approach may be different. How?

They use only regular insulin to lessen the problem of unpredictable absorption. Every four to five hours, the patient is given 5 to 15 units of the regular units. How many injections does this regimen make? Up to six injections a day, including the night time.

Severe cases, according to the brittle diabetes update, can be referred to specialty centers. This is important especially if health care team can lose objectivity because the patients become too familiar and bend the rules so they can stay in the hospital as their sanctuary.

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