Brittle Diabetes: A Contemporary Review of the Myth and Its Realization

Abstract

Type 1 Diabetes is an intrinsically unstable condition. A small group of patients with Type 1 Diabetes (3‰), mainly young women, suffer chronically by poor metabolic control, characterized by a severe instability of glycemic values with frequent and unpredictable hypoglycemic and/or diabetic ketoacidosis episodes which cannot be attributed to patients or clinicians errors. The quality of life of these patients is dramatically compromised in particular because of the frequency of acute events, hospital recoveries and precocious appearance of chronic complications. This clinical condition has been defined as "brittle diabetes" (Tattersall, 1977). A precise quantification of these patients is difficult because diagnostic criteria are still not well defined and it is often difficult to verify errors of patients in terms of inappropriate conduct with the pathology. Metabolic instability is manifested most obviously by chaotic glycemic profiles, which show greater and more unpredictable variation than in “stable” patients with diabetes. Patients with brittle diabetes cannot be controlled adequately, even by closely supervised, intensive insulin regimens, including continuous subcutaneous and/or intravenous insulin infusion (Bertuzzi et al., 2007). Their care is often very expensive of time and resources, and their lives are constantly at risk from metabolic catastrophe. Management of these patients can also be frustrating and demoralizing for all concerned, including the patient’s family and associates and the diabetes care team. This review will focus on a contemporary “painting” of brittle diabetes beginning with a few historical notes leading to its definition, ongoing researched pathophysiologic substrate, common and life-threatening clinical manifestations, diagnosis and treatment.