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BRITTLE DIABETES-CURRENT
APPROACH
BYDr.SRIKANTH
POST GRADUATE
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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.
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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.
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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
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• -Recurrent hypoglycemia• 1]Hypoadrenalism• 2]Hypothyroidism• Gastroparesis,celiac disease• Insulin autoimmune hypoglycemia• Post pancreatectomy surgery• Post chronic pancreatitis• Drugs[alcohol,antipsychotics]
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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
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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%}
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History and Examination
• Pubertal status in Children• Features of Mauriac Syndrome• Features of Endocrinopathies• Signs of chronic infection• Cutaneous manifestations • Drug history• Diabetes Knowledge
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Typical Diabetes Control
• 12-18% in recurrent ketoacidosis
• 4-6% in recurrent hypoglycemia
HbA1c levels
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EVALUATION CONTROL
• 2h Profile of glucose+insulin for 48h
• Supervision of insulin injections
• Psychosocial Assessment
• Diabetes education
• Screening for eating disorders
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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.
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MANAGEMENT Strategies in brittle diabetes
★ Qualification of glycemic variability★ 1]MAGE★ 2]MODD★ 3]LI★ 4]LBGI★ 5]CBGM★ 6]SMBG
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TREATMENT options• Lifestyle and education
• Psychotherapy
• Alternative medicine
• Insulin therapy
• Insulin pump therapy
• Islet transplantation
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COMPLICATIONS• Gastroparesis• Severe malnutrtion• Endocarditis• Intracranial,retropharyngeal,pulmonary infections• pulmonary edema • Cerebral edema• Spontaneous muscle infraction
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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 .
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THANK YOU