How to manage brittle diabetes mellitus (DM)?

Managing Brittle Diabetes: A Comprehensive Approach

Brittle diabetes requires intensive monitoring, individualized insulin regimens, and addressing underlying causes to prevent life-threatening glucose fluctuations and improve quality of life.

Definition and Epidemiology

• Brittle diabetes refers to cases where glycemic instability significantly disrupts life, often resulting in recurrent and/or prolonged hospitalization 1
• It affects approximately 3 per 1,000 insulin-dependent diabetic patients, primarily young women 1
• The condition is associated with poor prognosis, lower quality of life scores, more microvascular complications, and shortened life expectancy 1

Clinical Presentation

• Three main forms have been identified: recurrent diabetic ketoacidosis, predominant hypoglycemic forms, and mixed instability 1
• Patients experience unpredictable and severe fluctuations in blood glucose levels despite adherence to treatment regimens 1
• Diabetic autonomic neuropathy often manifests as resting tachycardia, exercise intolerance, orthostatic hypotension, gastroparesis, erectile dysfunction, and hypoglycemic unawareness 2

Underlying Causes

• Organic causes include:
  • Malabsorption issues 1
  • Defective insulin absorption or degradation 1
  • Defects in hyperglycemic hormones (glucocorticoids, glucagon) 1
  • Delayed gastric emptying due to autonomic neuropathy 1
  • Medication effects (alcohol, antipsychotics) 1
• Psychosocial factors play a significant role and may lead to a self-perpetuating condition 1

Assessment and Monitoring

• Quantification of blood glucose variability is essential for diagnosis and management 1
• Utilize specialized measures to quantify instability:
  • Mean Amplitude of the largest Glycemic Excursions (MAGE) 1
  • Mean Of Daily Differences (MODD) 1
  • Lability Index (LI) 1
  • Low Blood Glucose Index (LBGI) 1
  • Continuous glucose monitoring systems 1
• Continuous glucose monitoring significantly reduces severe hypoglycemia risk 3

Management Strategies

Insulin Therapy

• Most patients with Type 1 diabetes should be treated with multiple-dose insulin injections or continuous subcutaneous insulin infusion 3
• Use insulin analogues to reduce hypoglycemia risk 3
• Consider insulin pump therapy with low glucose suspend features to reduce nocturnal hypoglycemia 3
• Initial insulin dosage ranges from 0.25 to 1.0 U per kg per day, adjusted based on individual response 4

Continuous Glucose Monitoring

• Implement continuous glucose monitoring systems to identify patterns and prevent severe hypoglycemic episodes 3
• Target glucose levels should be individualized based on hypoglycemia risk, with less stringent goals for those with hypoglycemia unawareness 3

Lifestyle Modifications

• Engage in 150 minutes or more of moderate-to-vigorous intensity aerobic activity per week, spread over at least 3 days 2
• Include 2-3 sessions of resistance exercise on nonconsecutive days 2
• Reduce sedentary behavior and interrupt prolonged sitting every 30 minutes 2
• Implement a consistent carbohydrate intake pattern to match insulin dosing 3

Addressing Autonomic Neuropathy

• For gastroparesis, consider prokinetic agents and dietary modifications 2
• Manage orthostatic hypotension with appropriate interventions 2
• For painful diabetic neuropathy, consider medications such as tricyclic drugs, anticonvulsants, or duloxetine 2

Advanced Treatment Options

• For severe cases unresponsive to conventional therapy, consider:
  • Continuous Subcutaneous Insulin Infusion (CSII) 1
  • Isolated islet transplantation for patients with hypoglycemic unawareness/lability, especially if BMI < 25 1
  • Implantable insulin pumps for patients weighing more than 80 kg or with kidney/liver function abnormalities 1

Team-Based Care Approach

• Utilize a collaborative, integrated team with expertise in diabetes including physicians, nurse practitioners, nurses, dietitians, pharmacists, and mental health professionals 3
• Care management featuring nurses or pharmacists adjusting medications without prior physician approval has shown effectiveness in improving glycemic control 5
• Address psychosocial factors through appropriate mental health support 1

Prevention of Complications

• Regularly screen for diabetes complications including retinopathy, nephropathy, neuropathy, and cardiovascular disease 3
• Consider screening patients with type 1 diabetes for autoimmune diseases (thyroid dysfunction, celiac disease) 3
• Implement strategies to prevent hypoglycemia, including education on recognition and treatment 3

Common Pitfalls to Avoid

• Avoid therapeutic inertia - prioritize timely and appropriate intensification of therapy when targets aren't met 3
• Avoid sole use of sliding-scale insulin in hospitalized patients 3
• Don't aggressively pursue near-normal HbA1c levels in patients where such targets cannot be safely achieved 3
• Be vigilant about recognizing hypoglycemia in elderly patients, as it may be difficult to identify 6