An Overview of 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. This type of diabetes is very rare, but serious, and may require hospitalization.

The blood sugar levels of people with stable diabetes may fluctuate occasionally. However, these fluctuations are usually not frequent and—unlike brittle diabetes—do not impact their ability to carry out regular activities of daily living.

In contrast, people with brittle diabetes may experience frequent, unpredictable blood sugar shifts, from high to low or vice versa that happen rapidly and seemingly without cause and directly affect their quality of life. Brittle diabetes is also marked by a higher risk of severe hyperglycemia or ketoacidosis.

Quick-onset episodes of hyperglycemia and hypoglycemia are hallmarks of brittle diabetes. If you're regularly experiencing the following symptoms, get medical help immediately.

Symptoms of high blood sugar (hyperglycemia) include:

• Fatigue
• Blurry vision
• Excessive thirst
• Increased hunger
• Increased urination
• Fruity breath
• Nausea and vomiting

Symptoms of low blood sugar (hypoglycemia) include:

• Confusion
• Lack of energy, fatigue, tiredness
• Dizziness
• Headache
• Sweating
• Feeling shaky or anxious
• Increased heartbeat

According to the National Institutes of Health (NIH), only a small percentage of people with type 1 diabetes experience the frequent blood glucose fluctuations described as “brittle.” It affects approximately three out of 1000 insulin-dependent people with diabetes, mainly young women, with overweight women most likely to be affected. Most people diagnosed with brittle diabetes tend to be adolescents or young adults between the ages of 15 and 30.

The incidence of the disease is relatively rare in people over 40, which may suggest that the disease may resolve itself over time in some cases.

The most significant risk factor for brittle diabetes is having type 1 diabetes. Other risks include psychological issues such as depression or high stress. Stress can bring on acute, temporary insulin resistance, which may explain the sudden swings in glucose levels, and means that the body will not respond to insulin, which can make it very hard to predict your dosage.

In other cases, altered digestion as a result of nerve damage or another condition, such as Celiac disease or malabsorption, may be responsible. Autonomic neuropathy, or nerve damage affecting organ function, could compromise the digestive processes in place used to metabolize glucose and affect stomach and intestine function, making it difficult to judge how much insulin to take.

Other risk factors for brittle diabetes include:

• Eating disorders
• Gastrointestinal absorption problems, including delayed stomach emptying (gastroparesis)
• Celiac disease
• Drug interactions
• Problems with insulin absorption
• Hormonal malfunction
• Hypothyroidism
• Adrenal insufficiency

Diagnosis of brittle diabetes is fairly tricky. Typically, if diagnosed, it is usually coupled with psychological problems, such as stress and depression. In some cases, psychological problems lead to neglected self-care for diabetes. For example, people with brittle diabetes may stop maintaining a healthy diet or keeping up with the management of their blood sugar. As blood sugar control wanes, metabolic imbalances further complicate and often worsen the underlying psychological problems, causing a repetitive cycle of brittle diabetes.

One small study documented that people with brittle diabetes have a greater hormonal response to stress than those whose diabetes is not brittle. This psychological-hormonal connection may influence the development of brittle diabetes.

Identifying and correcting the underlying issues, whether physiologic or psychological, is essential to treating brittle diabetes. Blood tests can help to determine the cause of glucose instability. If blood glucose responds normally to diabetes drugs in a controlled environment (such as in a hospitalized patient), then one should look for environmental, psychological, or behavioral causes.

While there may be a physiological explanation for brittle diabetes, that's only one of the potential behavioral/environmental explanations, and diagnosing a psychological cause of brittle diabetes can often be a lengthy and challenging process.

If the cause is determined to be psychological, treatment may involve exploring and trying to lessen the stress of the person's situation. It is helpful to consult a psychology professional in evaluating and treating these patients. Psychotherapy has proven to be effective in treating brittle diabetes.

Patients with brittle diabetes may sometimes need to be transferred to a different diabetes care team for a fresh start in managing their diabetes. Switching to a specialty diabetes center can sometimes help to break the cycle of brittle diabetes.

Treating brittle diabetes may require a prolonged hospital stay of a few weeks with intensive monitoring of food, glucose, and insulin.

The more information you have regarding your blood sugars the better you can manage your medications and reduce the frequency of blood glucose excursions. For many people with type 1 diabetes, this may mean wearing a continuous glucose monitor and using an insulin pump. 

Continuous glucose monitors can help you to identify when your blood sugar is dropping or spiking so that you can take the necessary steps to get your sugar under control. Some come equipped with safety alerts and alarms to notify you of rising or dropping levels before they get too serious.

Insulin pumps can make insulin dosing much more precise. They aim to mimic how a normal-functioning pancreas would act, by delivering a small amount of basal insulin throughout the day to cover the body's need for insulin and delivering larger doses (bolus insulin) when you consume a meal or snack.

These pumps don't do all the work for you, however. You should still focus on a reduced carbohydrate diet to help minimize blood sugar swings, and regularly monitor your blood sugar. But when used properly, insulin pumps may enable you to better manage your insulin needs in the long run. 

Another option, if you are eligible, is islet cell transplantation. Islet cell transplantation, specifically allotransplantation, is currently being used on a very select population of people with type 1 diabetes who have an extremely difficult time managing their blood sugars or have a severe case of hypoglycemia unawareness. Transplants are only performed in clinical research hospitals that have had approval by the FDA.

People with brittle diabetes are frequently hospitalized, regularly miss work, and often have to contend with psychological problems. All of these factors place additional emotional and financial stress on family members. It's important that you reach out to your medical team for support for yourself and your family members.

Brittle diabetes, or labile diabetes, is a very rare condition characterized by extreme swings in blood sugar. Oftentimes, people with brittle diabetes also have another underlying condition, such as depression, extreme stress, hormonal dysfunction, or hypothyroidism, to name a few. Knowing the signs and symptoms of both high and low blood sugar, as well as getting psychological support and making efforts to reduce your stress can help to lessen the burden on your body.

Work with a holistically minded care team to employ stress reduction practices such as meditation, deep breathing, gentle yoga, and acupuncture, along with psychotherapy, supplements, and medication as necessary.