A new look at brittle diabetes
Brittle diabetes was first defined as a life disrupted by episodes of hypoglycemia or hyperglycemia. Early descriptions were mainly from small case reports of mostly young women with recurrent diabetic ketoacidosis, psycho-social instability, poor patient compliance or maladaptation. Irl B. Hirsch and colleagues published a research paper in Journal of Diabetes and its Complications under title “A new look at brittle diabetes”. The summary of this article is given below:
To redefine brittle diabetes and its different stages.
The information was developed from the currently available evidence and scientific and medical knowledge on the topic of interest.
Independent to the causative factor brittle diabetes patients are at risk for many unfortunate consequences such as more emergency room and hospital admissions, poor glycemic control with its complications, greater healthcare utilization, strains on relationships, and diabetes distress. Its helpful to segregate these patients with into four groups which happen to cluster according to lifespan to some degree. This are as follow:
1) DKA/hypoglycemia-prone due to psychological disease
This group often contain young women ranging in age from 8 to 33 years. The group is described as “mixed brittleness” with episodes of recurrent DKA and severe hypoglycemia. The reports highlight that there is profound psychosocial problems that challenge all patients with diabetes.
Treatment approach:- Referral to mental health providers, ideally knowledgeable in diabetes. The treatment often require family counselling.
2) Severe glucose variability due to co-existing medical condition
There are many uncommon medical conditions that result in brittle diabetes. Some of the conditions such as thyrotoxicosis, Cushing’s Syndrome glucagonoma, acromegaly, diabetic gastroparesis, alcohol, lipohypertrophy from repeated insulin injections, and pheochromocytoma were reported to be associated with DKA. Additionally, there are genetic etiologies of insulin resistance that results in brittle diabetes.
Treatment approach:- Record history, physical exam and laboratory evidence to support a specific etiology of brittle diabetes. Appropriate treatment and referral as indicated.
3) Geriatric type 1 diabetes
There is increase in number of older adults with type 1 diabetes. Elderly patients come across many challenges such as concerns with remembering to administer insulin or taking it twice, decline in cognition with age, independent self-management of diabetes becomes problematic, acute glycemic emergency, inexperience family member or care giver.
Treatment approach:- administer CGM when available, will often require extensive family support, many skilled nursing staff are not equipped to assist this patients.
4) Insulin and food insecurity
Lack of access for insulin in low-income countries is a major cause of pediatric mortality. Limited access to adequate and safe foods as compared to access to insulin is another problem in low income countries.
Treatment approach : most important is diagnosis by screening, for some may be assisted by medical social worker.
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