Brittle Diabetes

Author: Judy Kohn, RN, BSN, CDE

Last Updated: Monday, February 13, 2006

Q: "Can you please explain the concept of "brittle" diabetes vs. the theory it is just not controlled? Also, does the length of the disease make a difference in one's ability to control it?"

A: The term Brittle Diabetes refers to the problem of wide, unpredictable and uncontrollable swings in blood glucose, usually in people who inject insulin. This term has been around a long time, and previously was "overused and abused" before home blood glucose monitoring became available. There was a time when I often heard such comments as: "I'm brittle-no matter what I do, my blood glucose jumps all over, for no explainable reason, and no one can control my diabetes."

It is true that some people do have an unusual or exaggerated response to food, medication, or stress, and despite their trying to be consistent with their diabetes regimen, their control is erratic. However, diabetes specialists now know that there are far fewer "true brittle" people with diabetes, because generally the swings of blood glucose have a preventable or treatable cause. Here are some situations that can cause erratic blood glucose levels:

• Insulin errors or variables:
  • Are you measuring the dose correctly?
  • Do you properly mix the cloudy insulin adequately before drawing it up?
  • Do you inject your insulin at the proper depth, and consistently each day? Are you aware that when injecting some types of insulin, that insulin absorption rate varies according to the injection site?
  • Do you rotate your injection sites by a particular pattern/schedule, to avoid forming scar tissue?
  • Do you allow the proper and consistent timing between your insulin shot and your meal?
  • Do you smoke? Smoking can affect insulin absorption.
  • Do you avoid injecting insulin in an exercised limb (for example, do not inject insulin in the thigh just before riding your bike--the exercise will speed up the absorption of the insulin, and could cause early hypoglycemia with later hyperglycemia the same day).
  • We never realized years ago that cloudy insulin (i.e. the intermediate-acting insulins) can vary from day to day approximately 25% --and sometimes up to 50%-- while clear insulin (i.e. short or rapid-acting insulin as well as the new long-acting insulin analogues) supposedly varies less than 3%. Many people previously labeled "brittle" became very well controlled once they switched to either multiple shots of short or rapid-acting insulin before meals with a long-acting insulin analogue (such as Lantus® or Detemir® at bed, or to an insulin pump. Thus, the conclusion with these people was that the cloudy insulin's variability was the likely cause of their erratic blood glucose levels.
  • Have you verified your insulin sensitivity scale, using either the 1500 rule (or 1700 or 1800) rule? Do you respect the "unused insulin rule" to make sure you don't inject insulin too soon after the previous injection to avoid what is called "stacking insulin?"
• Monitoring errors:
  • Have you had your glucose monitoring technique reviewed by a diabetes educator? Have you confirmed that your meter reads fairly close to the laboratory glucose, when measured at the same time?
  • Is your meter calibrated correctly (i.e. on the proper code)?
  • Are your strips stored correctly, and used within the expiration date?
  • Are you testing as often as you should, to be able to obtain an adequate pattern of your glucose levels?
  • Are you testing at consistent and appropriate times? Do you note if the glucose reading is pre-meal or post-meal, since there are different target goals for each?
  • Do you keep accurate and adequate records, explaining variations in routine, such as stress, illness, activity, over or under-eating?
• Meal errors:
  • Are you following a reasonably consistent meal plan as recommended by a registered dietitian, preferably certified as a diabetes educator?
  • Do you follow a carbohydrate counting diet, aiming for consistent amounts of carbohydrates each meal?
  • Do you have a specific insulin- to- carbohydrate ratio, so that you can vary your insulin dose according to the amount of carbs ingested?
  • Are you measuring or estimating the portion sizes correctly?
• Emotional factors:
  • Are you aware of the effect of stress on your body?
  • Do you experience frequent episodes of stress?
  • Have you learned how to manage your stress effectively?
  • Are you getting enough sleep overall to feel refreshed at the start of each day?
• Hypoglycemia:
  • Do you have frequent episodes of low blood sugar? After a hypoglycemic episode, you can have a temporary rebound/rise in your blood glucose.
  • Do you treat hypoglycemia appropriately, without overeating?
  • Do you sometimes think you are low, and eat, without first testing to confirm if you are really low?
• Neuropathy (nerve damage):
  • Do you have gastroparesis (nerve damage that affects the rate the stomach empties)? This can cause a mismatch of your insulin and food-i.e. your insulin would absorb before the food is released from the stomach, resulting in hypoglycemia during or right after a meal, followed by hyperglycemia later.
  • "Diabetes Overwhelmus": This is a term coined by Richard Rubin, Ph.D , CDE, who speaks eloquently about all the emotional challenges of coping with diabetes. As I wrote this answer, I gained a deeper respect for all the issues you have to consider on a daily basis. Please realize that there are many causes for erratic diabetes control-but sometimes, there just isn't an explainable reason. I hope you'll take these ideas under consideration and discuss them with your healthcare professional.

Regarding whether or not the length of time you have diabetes determines your ability to control it: The answer to this could be yes, no, or maybe.

• Type 2 diabetes: Type 2 diabetes is a progressive disease, meaning that over time, most people will require more diabetes medication, and many will eventually require insulin. So in this case, one could say that diabetes becomes more difficult to control--or at least requires more medication--the longer you have it, as the pancreas's ability to produce insulin declines.
• Kidney function: If your kidney function declines, your diabetes medication (oral agents or insulin) is not excreted at the same rate, which can cause erratic or difficult diabetes control.
• Neuropathy: If you develop nerve damage, you might have various problems such as the inability to recognize low blood glucose (called hypoglycemia unawareness), pain from peripheral neuropathy, which can then affect your blood glucose, or gastroparesis, as explained above, among other symptoms.
• Scar tissue build-up at injection sites: Some people develop significant lumps/scar tissue from years of injecting insulin-made worse if they don't rotate their sites adequately. Such tissue can cause erratic absorption, so in this case, some people feel their diabetes is more difficult to control due to the limited areas available in which to inject insulin.
• Looking on the positive side: Despite the issues just described, what I see often is that we have developed many more strategies to help you control your diabetes:
  • Multiple shots or insulin pumps, along with newer insulin analogues, have dramatically improved diabetes control for many people so that they feel their diabetes is easier to control now than it was in the past.
  • Carbohydrate counting principles have not only improved control but also have provided you the ability to follow a much more liberal and varied meal plan compared to what you would have been prescribed years ago.
  • There are more drugs for diabetes, blood pressure, neuropathy, etc. so that we have many more tools and choices to help you with an individualized plan of care.
  • Research is ongoing, searching for more options/solutions, including: different ways to deliver insulin, different drugs to target diabetes defects, continuous glucose monitoring, drugs to prevent the complications, as well as other developments on the horizon. So hopefully in the future, we'll be able to say unequivocally that diabetes has become easier to manage.

I would recommend you review the other answers in the archives as you will be able to learn more about managing diabetes.

Related Links

Diabetes Self-Management
http://www.diabetesselfmanagement.com

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