BRITTLE DIABETES-CURRENT

APPROACH

BYDr.SRIKANTH

POST GRADUATE

INTRODUCTION• Almost all diabetic patients experience

swings in blood glucose levels ,which are larger and less predictable than in non diabetics.

• When these swings become intolerable and cause distruption to person daily life the person is able to have brittle diabetes.

HISTORY• In 1942 the chicago physician Woodyatt

introduced concept of brittle diabetes.

• In 1950s the question was whether they were two Distinct group of patients.

• In 1977 Tattersall defined brittle diabetes as patients who”s life was constantly disturpted by episode of hypo- or hyperglycemia

• In 1980 group investigation.

ETIOLOGY• Psychological[most comon]

• Nonphysiologic matching of meals,exercise and insulin

• Poor adherence /compliance to treatment

• Chronic infections

• Chronic medical illness

• Endocrinopathies

• -Recurrent Ketoacidosis

✦ 1]Acromegaly

• -Recurrent hypoglycemia• 1]Hypoadrenalism• 2]Hypothyroidism• Gastroparesis,celiac disease• Insulin autoimmune hypoglycemia• Post pancreatectomy surgery• Post chronic pancreatitis• Drugs[alcohol,antipsychotics]

Rare causes

• Mauriac syndrome:It is rare complication of type 1 DM characterized by extreme hepatomegaly due to glycogen deposition,along with growth failure and delayed puberty.

• Polyglandular autoimmune syndrome

CLINICAL MANIFESTATIONS

✤ Three clinical forms of brittle diabetes have been describe

• 1]Predominant hyperglycemia with recurrent ketoacidosis{59%}

• 2]Predominant hypoglycemia{17%}

• 3]Mixed hyper-hypo glycemia{24%}

History and Examination

• Pubertal status in Children• Features of Mauriac Syndrome• Features of Endocrinopathies• Signs of chronic infection• Cutaneous manifestations • Drug history• Diabetes Knowledge

Typical Diabetes Control

• 12-18% in recurrent ketoacidosis

• 4-6% in recurrent hypoglycemia

HbA1c levels

EVALUATION CONTROL

• 2h Profile of glucose+insulin for 48h

• Supervision of insulin injections

• Psychosocial Assessment

• Diabetes education

• Screening for eating disorders

IF INDICATED• Gastric emptying tests

• Insulin &Insulin Receptors Antibodies

• Screening for drugs or Abuse

• Insulin Challenge Test:0.1 U/Kg injected SC or IV and comparision of insulin&glucose profiles with normal ranges.

MANAGEMENT Strategies in brittle diabetes

★ Qualification of glycemic variability★ 1]MAGE★ 2]MODD★ 3]LI★ 4]LBGI★ 5]CBGM★ 6]SMBG

TREATMENT options• Lifestyle and education

• Psychotherapy

• Alternative medicine

• Insulin therapy

• Insulin pump therapy

• Islet transplantation

COMPLICATIONS• Gastroparesis• Severe malnutrtion• Endocarditis• Intracranial,retropharyngeal,pulmonary infections• pulmonary edema • Cerebral edema• Spontaneous muscle infraction

SUMMARY• Severely unstable,or brittle, diabetes can be

disruptive to patients

• The peak age group of brittle diabetes is 15-30.

• In younger patients the principal manifestation brittle diabetes is recurrent ketoacidosis.

• In elderly the manifestation is recurrent hypoglycaemia .

THANK YOU