What is Brittle Diabetes?

Brittle diabetes, also called labile diabetes, is diabetes that is hard to control. It is characterized by extreme swings in blood sugar levels, from too high (hyperglycemia) to too low (hypoglycemia) or vice versa. Some experts regard brittle diabetes as a subtype of type 1 diabetes while others believe it to be a complication of the disease. Either way, it's rare, affecting only about three out of 1000 people with diabetes who are dependent on insulin. Brittle diabetes often is associated with stress and other psychological issues and may require hospitalization.

Symptoms

The hallmark of brittle diabetes is frequent, unpredictable shifts in the levels of glucose in the blood, causing fluctuating symptoms of hyperglycemia (high blood sugar) and hypoglycemia (low blood sugar).

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

Brittle diabetes also is marked by an increased risk of diabetic ketoacidosis (DKA), in which abnormally high levels of ketones—a byproduct of the breakdown of body fat—build up in the blood. Ketoacidosis can lead to diabetic coma and even death.

Symptoms of diabetic ketoacidosis include:

• Excessive thirst
• Increased urination
• Lack of energy, fatigue, tiredness
• Fruity breath
• Dry or flushed skin
• Confusion
• Nausea or vomiting

Ketoacidosis can be confirmed by testing urine for ketone levels. DKA usually sets in slowly, but when vomiting occurs due to DKA, in just a few hours it can develop into a life-threatening condition. If you or a loved one are showing signs of DKA, seek immediate medical help.

Causes

Brittle diabetes may be caused by several factors, including 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 the body will not respond to insulin, which can make it hard to predict your dosage.

In other cases, brittle diabetes may be caused by altered digestion as a result of nerve damage or another condition, such as celiac disease or malabsorption. 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.

Risk Factors

The primary risk factor for having brittle diabetes is having type 1 diabetes. But you're also more likely to develop the condition if you're young: Most people diagnosed with brittle diabetes are adolescents or young adults between the ages of 15 and 30.

The disease is relatively rare in people over 40, suggesting it may resolve itself over time in some cases.

Some studies suggest that women are more likely to be affected than men.

Other risk factors for brittle diabetes include:

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

Diagnosis

The diagnosis of brittle diabetes is tricky. While there's a lack of precise metrics to be used for diagnosis, the disease is marked by recurring, large swings in blood sugar levels (either too high or too low) that are hard to predict, negatively affect quality of life, and require frequent hospitalization. Because of the lack of precision in the term "brittle diabetes," some physicians now simply diagnose the phenomenon as "high glucose variability" and work to treat the underlying issue, be that recurring DKA or severe hypoglycemia.

Typically, brittle diabetes 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 adequately managing their blood sugar. As blood sugar control wanes, metabolic imbalances further complicate and often worsen the underlying psychological problems, causing a repetitive cycle of glucose instability.

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

Treatment

Balancing blood glucose levels to avoid erratic swings is the most effective way to treat brittle diabetes. Treatment may first require a hospital stay of a few weeks with intensive monitoring of food, glucose, and insulin to restore better glucose control.

Continuous glucose monitors and insulin pumps can be useful in the ongoing management of hypo/hyperglycemia, and newer technologies such as an artificial pancreas may be helpful, as well.

Continuous Glucose Monitors and Insulin Pumps

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

Continuous glucose monitors can alert you to dips or spikes in your blood sugar so you can take the necessary steps to get it 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 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) each time you eat a meal or snack.

You should still keep track of your food intake 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 in the long run. 

Psychological Treatment

Oftentimes, people with brittle diabetes have an underlying psychological condition, such as depression or extreme stress, that makes it difficult to effectively manage their blood sugar fluctuations. 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.

If your glucose levels respond normally to diabetes drugs in a controlled environment (such as in a hospital setting), then it's possible that there may be environmental, psychological, or behavioral causes at play for your glucose swings. If the cause is determined to be psychological, treatment may involve exploring and trying to lessen the stress your situation. It's helpful to consult a psychology professional for evaluation and treatment. Psychotherapy has proven to be effective in the long-term treatment of diabetes.

Medication for anxiety or depression also may help, however, be aware that some medications may interact with your diabetes medications. Beta-blockers and some mood stabilizers, for example, may worsen symptoms of diabetes, and others may affect how your diabetes medications act in your body. Work with your endocrinologist and your psychiatrist to find a treatment option that's a good fit for you.

In some cases, transferring to a different diabetes care team can serve as a helpful fresh start. Switching to a specialty diabetes center also can sometimes help break the cycle of brittle diabetes.

Additionally, work with a holistically-minded care team to employ stress reduction practices for daily life such as meditation, deep breathing, gentle yoga, and acupuncture, alongside psychotherapy and medication as necessary.

Transplantation

Another option, if you are eligible, is to receive a pancreas transplant or undergo islet cell transplantation. Islet cell transplantation, specifically allotransplantation, is used for a select population of people with type 1 diabetes who have a difficult time managing their blood sugar or have hypoglycemia unawareness. Transplants are only performed in clinical research hospitals that have had approval by the U.S. Food and Drug Administration.

New Technologies

Two models of an artificial pancreas, a device that essentially serves to act as a human pancreas by automating insulin dosages in response to a rise in glucose levels, have been approved by the U.S. Food and Drug Administration (FDA). Both models use hybrid closed-loop technology that automates insulin release—meaning users only need to adjust insulin levels at meals. These systems can help take some of the guesswork out of insulin adjustments, as they happen automatically with less required oversight.

Coping

People with brittle diabetes are frequently hospitalized, regularly miss work, and often have to contend with psychological problems. All 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.

A Word from Verywell

Diabetes, especially type 1 diabetes, is a lifelong condition for many, requiring consistent and sometimes constant oversight and management. This fact can be overwhelming and highly stressful, but there are resources that can help. Because brittle diabetes can be closely linked to mental health, seek out a therapist or psychologist who can help you come up with a plan to successfully manage your condition and keep on top of any underlying stress or depression that may negatively impact your glucose control.