By Saima Ali, M.D.
Board Certified Endocrinologist
Saint Anthony's Physician Group
Less than one percent of individuals with diabetes have a condition known as brittle diabetes, characterized by extreme and dangerous swings in blood sugar levels. Some persons tend to swing toward episodes of hypoglycemia (low blood sugar), others toward hyperglycemia or ketoacidosis (high blood sugar). Yet others have a mixed type, with swings in both directions.
While all diabetics can and do suffer highs and lows of blood sugar, brittle diabetics have more extreme and more frequent fluctuations, causing recurring hospitalizations, missed work and considerable disability as well as the risk of death.
Ketoacidosis involves a nearly complete lack of the insulin that’s needed to allow body cells to utilize blood sugar. As the body searches frantically for energy from other sources, acids in fat cells are broken down by the liver into ketones, raising the acidity of the blood to dangerous levels.
At the same time, a high level of glucose in the blood causes the body to excrete large amounts of sugar and water in urine, leading to severe dehydration.
Hypoglycemic attacks occur when blood sugar levels drop dangerously low, typically because the patient has administered too much insulin or oral medication relative to the amount of food that has been eaten. This may also happen when a meal is delayed or missed or when the patient exercises without eating a snack beforehand.
When the patient notes the protective symptoms – sweating, palpitations, nervousness, hunger, faintness, weakness, headaches, poor coordination, inappropriate behavior and confusion – he or she can correct the condition by quickly taking a sugary food or drink. When these symptoms are missed or ignored, the result is a life-threatening coma.
Brittle diabetes can have a number of physiological causes such as absorption problems in the intestines, delayed stomach emptying, drug interactions, poor insulin absorption or malfunction of the thyroid or adrenal glands.
Brittle diabetes can and often does occur, however, with no detectable physical cause. Many cases appear to be related to psychological, social or environmental factors, including neglecting to monitor blood sugar closely enough and failing to take prescribed insulin and other medications at the proper time. Brittle diabetes is strongly associated with depression and stress.
The problem often occurs among young women, ages 15 to 30, many of whom are overweight or obese. Around the time of puberty, both males and females with Type 1 diabetes often have trouble controlling blood sugar, sometimes for social reasons.
Some studies have found a second period of peak prevalence in later life, usually between ages 60 and 70. Brittle diabetes among the elderly has not been the subject of much research, but there are indications that it may follow a different pattern in older patients.
At any age, one or two episodes of high or low blood sugar can cause changes in metabolism that can make future episodes more likely. Stress, anxiety and depression are also likely to increase after one or two attacks, leading to a cycle that reinforces brittle diabetes metabolism. Quick action is needed.
The first step is to identify and correct the underlying cause. And this is never easy. Blood tests can be helpful in tracking any physical causes of blood sugar instability. Does blood glucose respond as it should to insulin or other diabetes medications? Are thyroid levels low? Was there a period when blood sugar was stable? If so, were there changes that took place–in medications, medical conditions, environment, mood – at the time instability started?
When the cause is primarily physical, then the patient may benefit from a continuous insulin pump to give more precise control over blood sugar. The pump, however, requires vigilant blood sugar monitoring and is not suitable for every patient with brittle diabetes.
A new tool for managing blood sugar was added about a decade ago with the approval of pramlintide, a synthetic analog of the hormone amylin. In non-diabetics, amylin plays a role in preventing dramatic swings of blood glucose. And correction of amylin deficiency through pramlintide has been found to help regulate blood sugar control in both Type 1 and Type 2 diabetics.
When no physical cause is found, then other reasons for poor blood sugar control must be sought. Psychotherapy has been found effective for some patients with brittle diabetes. Most doctors consider a mental health referral fairly early in the diagnosis and treatment process.
If there is a specific unhappy life situation, dealing with the problem frequently helps relieve the brittle diabetes. In some cases, the best strategy may be to start the patient with a new physician and diabetes care team – providing a fresh and objective approach.
While brittle diabetes is rare, it raises the specter of serious consequences. With early attention and patience, solutions can usually be found.
Dr. Ali is a board-certified endocrinologist with Saint Anthony’s Physician Group. For an appointment with Dr. Ali or for more information, call 618-462-2222.