What are the management strategies for brittle diabetes (Diabetes Mellitus)?

From the Guidelines

Brittle diabetes management requires a highly individualized and intensive approach, prioritizing the prevention of hypoglycemia and the optimization of quality of life, as emphasized in the most recent guidelines 1. To achieve this, patients should utilize continuous glucose monitoring (CGM) systems, such as Dexcom G6 or FreeStyle Libre, in conjunction with insulin pumps for precise insulin delivery.

• A basal-bolus insulin regimen is crucial, typically involving rapid-acting insulins (e.g., Humalog, NovoLog, or Fiasp) for meals and long-acting insulins (e.g., Lantus, Levemir, or Tresiba) for basal coverage.
• Carbohydrate counting should be precise, aiming for consistent carbohydrate intake at regular mealtimes to minimize glucose fluctuations.
• Patients should maintain detailed logs to track insulin doses, blood glucose readings, food intake, physical activity, stress levels, and illness, facilitating the identification of patterns and the adjustment of treatment plans. Regular visits to an endocrinologist, ideally every 1-3 months, are necessary to review progress, adjust insulin regimens, and address any emerging issues. Psychological support is also vital, as stress and mental health issues can significantly impact glucose stability and overall well-being. Addressing potential underlying causes of brittle diabetes, such as gastroparesis, thyroid disorders, or adrenal insufficiency, is essential for effective management. The goal of treatment should be to balance the stringency of glycemic targets with the risks of hypoglycemia, as highlighted in recent research 1, and to prioritize the patient's quality of life and preferences in the management plan, in line with the standards of care in diabetes 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 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 management of brittle diabetes requires careful consideration of the potential risks associated with changes in the insulin regimen. Changes in insulin strength, manufacturer, type, injection site, or method of administration may affect glycemic control and increase the risk of hypoglycemia or hyperglycemia.

• Key factors to consider when managing brittle diabetes include:
  • Close medical supervision
  • Increased frequency of blood glucose monitoring
  • Adjustments to concomitant anti-diabetic products
  • Patient education on recognizing and managing hypoglycemia and hyperglycemia 2

From the Research

Brittle Diabetes Management

• Brittle diabetes is a condition characterized by unstable blood glucose levels, resulting in disruption of life and often recurrent and/or prolonged hospitalization 3.
• It affects 3/1000 insulin-dependent diabetic patients, mainly young women, and has a poor prognosis with lower quality of life scores, more microvascular and pregnancy complications, and shortened life expectancy 3.
• The main causes of brittleness include malabsorption, certain drugs, defective insulin absorption or degradation, defect of hyperglycemic hormones, and delayed gastric emptying as a result of autonomic neuropathy 3.

Assessment and Treatment

• 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) 3.
• Therapeutic strategies require firstly, the treatment of underlying organic causes of the brittleness whenever possible, and secondly optimising standard insulin therapy using analogues, multiple injections, and consideration of Continuous Subcutaneous Insulin Infusion 3.
• Alternative approaches, such as isolated islet transplantation (IIT) and implantable pumps, may still be needed for the most severely affected patients 3.

Intensive Insulin Therapy

• Intensive insulin therapy (IIT) aims at achieving near-normal glycemic control and usually uses a basal-bolus schema to mimic physiologic insulin secretion 4.
• IIT has been shown to be effective in reducing glycated hemoglobin levels in both type 1 and type 2 diabetes, but is associated with a higher rate of severe hypoglycemia and weight gain 4.
• The use of long-acting insulin analogs and insulin pump therapy are also effective in managing brittle diabetes, with insulin pump therapy being the best current therapeutic option for some type 1 diabetic subjects 5.