From Arizona, U.S.A.:
I would like info on brittle diabetes, with hypoglycemic unawareness.
This question was referred to two members of the Diabetes Team, who have each given an answer:
Answer from Dr. Lebinger:Brittle diabetes is a term which has been loosely used for many years to describe individuals with difficult to control diabetes. Although there is no strict definition of "brittle diabetes" it usually refers to individuals who have wide swings in their blood sugars from lows to highs, often with ketosis.
There have been many attempts to explain why some individuals are more "brittle" or harder to control than others. Such possible explanations include irregularity in one's daily schedule, psychological stress, differences in the way insulin works in some individuals compared to others, rebound hyperglycemia (high blood sugars with or without ketosis following low blood sugars) and hypoglycemia unawareness.
The term hypoglycemia unawareness refers to the situation where individulas lose the early warning symptoms of low blood sugar. These early warning symptoms (hunger, sweating, headache, trembling, dizziness) occur as the blood sugar is falling and warn the individual to eat before the blood sugar falls into the dangerously low range where he could pass out or have a seizure. If you don't have these warning symptoms, you can't detect and treat a low blood sugar before it becomes incapacitating. Hypoglycemia unawareness has been reported to occur in individuals with very tight control. It seems that the body can get used to low blood sugars and think they are "normal" and not give you the warning symptoms. In addition, this problem can occur in individuals with longstanding diabetes with complications of the nervous system (autonomic neuropathy). These individuals do not respond properly to the falling blood sugar and do not make the hormones necessary to warn you of the falling blood sugar because of damage to the nerves that are supposed to detect the fall in blood sugar.
In my personal opinion, I also think there are individuals who have a very difficult time controlling their blood sugar for reasons which we do not yet understand. These individuals may try just as hard or even harder than some individuals with better control. I hope in the future we will have a better understanding why some people seem to be more "brittle" than others.
Answer from Dr. Robertson:This question encompasses almost the whole of diabetes - at least when it's not running smoothly. Brittle diabetes is a term coined to describe those patients who are usually on large doses of subcutaneous insulin, who have wild swings in their blood sugars and frequent admissions to hospital with ketoacidosis and/or hypoglycaemic attacks.
Diabetes professionals have discussed such patients for years without coming to any real conclusions about the cause. In a few patients there will be some other illness interfering with control of their diabetes but this is quite rare and most often nothing specific is found.
The hypoglycaemic unawareness may be related to frequent hypos because this is known to reduce warning signs - as do severe hypos.
A number of different approaches may be tried before the "brittle" patient settles back into a routine but most do eventually. Some such patients stabilise on pumps and, very rarely, an implantable pump is required. This is a very difficult problem and often the whole family have to be involved in helping the patient.
Original posting 6 Aug 96
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