What is the management of brittle diabetes (Diabetes Mellitus)?

From the Guidelines

Brittle diabetes, particularly type 3c diabetes, requires an individualized approach to management, focusing on regular monitoring, patient-specific meal plans, and alcohol avoidance to prevent hypoglycemic events and reduce the frequency and extent of hyperglycemia 1.

Key Considerations

• Type 3c diabetes, associated with pancreatic disease, is often misclassified as type 2 diabetes but has distinct clinical and metabolic factors that require tailored management strategies.
• Patients with type 3c diabetes tend to be undernourished, have nutrient deficiencies, and experience malabsorption, excess alcohol intake, and poor dietary intake, complicating their management.
• The characteristic "brittle" nature of type 3c diabetes, with erratic swings in blood glucose levels, necessitates a comprehensive approach that includes medical nutrition therapy, monitoring, and lifestyle adjustments.

Management Strategies

• An individualized medical nutrition therapy program is vital, emphasizing regular monitoring and recording of blood glucose levels, alcohol avoidance, and patient-specific meal plans to reduce hyperglycemia and prevent hypoglycemia.
• Psychological support is crucial, as stress can exacerbate glycemic instability, and addressing underlying causes of brittleness, such as hormonal imbalances or medication interactions, is essential.
• The use of empowering language in diabetes care and education can help motivate patients and inform them about their condition, while language that shames can hinder progress 1.

Treatment Goals

• The primary goals of treatment for brittle diabetes are to prevent or delay complications, optimize quality of life, and improve disease outcomes through collaborative and personalized management plans 1.
• Treatment plans should be created with patients based on their individual preferences, values, and goals, taking into account their age, cognitive abilities, health beliefs, and support systems.
• Regular assessment and addressing of self-management barriers without blaming patients for "noncompliance" or "nonadherence" is crucial for establishing a collaborative relationship and improving disease outcomes 1.

From the FDA Drug Label

5 WARNINGS AND PRECAUTIONS

5.2 Hyperglycemia or Hypoglycemia with Changes in Insulin Regimen Changes in an insulin regimen (e.g., insulin, insulin strength, manufacturer, type, injection site or method of administration) may affect glycemic control and predispose to hypoglycemia [see Warnings and Precautions (5. 3)] or hyperglycemia.

The FDA drug label does not answer the question.

From the Research

Definition and Characteristics of Brittle Diabetes

• Brittle diabetes is an unstable condition characterized by severe instability of glycemic values with frequent and unpredictable hypoglycemic and/or diabetic ketoacidosis episodes 2.
• It is a life-disrupting condition that affects the quality of life of patients, leading to frequent hospital admissions and premature chronic complications 2, 3.
• Brittle diabetes can occur in different life stages, including younger patients with associated psychiatric diseases, individuals with underlying medical conditions, geriatric patients with type 1 diabetes, and those with lack of insulin access and food insecurity 4.

Causes and Risk Factors of Brittle Diabetes

• The causes of brittle diabetes can be diverse, including psychological abnormalities, malabsorption, certain drugs, defective insulin absorption or degradation, and delayed gastric emptying due to autonomic neuropathy 3, 5.
• Psychosocial factors, such as factitious brittleness, can also contribute to the development of brittle diabetes 5.
• Underlying organic causes, such as malabsorption and certain drugs, should be treated whenever possible to manage brittle diabetes 5.

Management and Treatment of Brittle Diabetes

• The management of brittle diabetes requires a team approach, involving a broad range of disciplines, to help patients achieve and maintain normoglycemia and quality of life 2.
• Therapeutic strategies include optimizing standard insulin therapy using analogues, multiple injections, and consideration of Continuous Subcutaneous Insulin Infusion 5.
• Alternative approaches, such as isolated islet transplantation and implantable pumps, may be needed for severely affected patients 5.
• Insulin glargine, detemir, and lispro protamine can be effective in reducing glycaemic variability and improving glycaemic control in people with type 1 diabetes 6.

Assessment and Monitoring of Brittle Diabetes

• The assessment of brittle diabetes requires quantification of the variability of blood glucose levels, using measures such as Mean Amplitude of the largest Glycemic Excursions (MAGE), Mean Of Daily Differences (MODD), and Lability Index (LI) 5.
• Continuous blood glucose monitoring can be used to quantify instability and monitor the effectiveness of treatment 5, 6.