Brittle diabetes as the name suggests is the wide variation in blood sugars after a minute change in insulin dose. An increase in one or two units can cause hypoglycemia and vice versa i.e. marked hyperglycemia with a slight decrease in insulin.
Brittle diabetes almost always occurs in type 1 diabetes but can also be seen in patients with type 2 diabetes complicated by renal diseases, hepatic diseases or other major systemic illnesses.
A story of the patient above with Brittle diabetes …
This is a young patient who was admitted with us for uncontrolled blood sugars and stunted growth.
Can you guess his age?
He was diagnosed with Diabetes Mellitus at the age of 2 years and had normal milestones at birth but growth rate declined after was diagnosed.
The patient was started on insulin but was very non-compliant to treatment and diet. He was repeatedly admitted with high blood sugars and diabetic ketoacidosis.
The patient was admitted for workup of stunted growth and uncontrolled blood sugars.
He had absent secondary sexual characteristics, sparse hair, poor dentition with a normal systemic examination.
His bone age was 10 years. He had a low serum TSH and T 4 levels.
Basal growth hormone levels were low. Blood sugars ranged from 35 to 600 mg/dl with glycated hemoglobin of 13%.
He was started on four units of regular insulin but had repeated hypoglycemia. Insulin was reduced to 2 units but hypoglycemia persisted.
He was shifted to twice daily insulin but blood sugars were recorded as greater than 500 mg/ dl. He was shifted to once daily long-acting insulin 6 units but sugars remained above 500 mg/dl.
Rapid-acting insulin was advised along with long-acting insulin.
Management issues in this patient with Brittle Diabetes
- Marked fluctuation in blood glucose with slight changes in insulin.
- Poor compliance to diet because of poverty, poor social support, and illiteracy.
- Stunted growth and absent secondary sexual characteristics.
- Complications of diabetes
How to address these issues?
Ideally, this patient needs insulin infusion pump to improve his glycemic control. Since insulin infusion pump is very costly and not available in Pakistan, this is not an option for him.
The other remote treatment strategy in an ideal situation would be pancreatic islet transplantation.
Rapid-Acting insulin was arranged via Zakat and donations from friends and added to his insulin regimen as a basal-bolus regimen.
Dietary advice was given and reinforced with pictorial charts. The patient was educated about Symptoms of hypoglycemia and hyperglycemia and was educated about how to manage these emergencies at home.
Growth hormone and sex steroids replacement was not advised at the moment.
If the patient starts gaining weight and blood glucose normalizes, growth hormone replacement may need to be initiated followed by sex steroids.
The patient was asked to follow after 2 weeks with glucose record.
Question. Can you guess his age?
Answer. This patient’s actual age is 18 years.
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