Causes of Brittle Diabetes and How to Manage It

Table of Contents
View All
Table of Contents

Brittle diabetes, also called labile diabetes, is type 1 diabetes that is hard to control. It is characterized by frequent and severe swings in blood sugar (glucose) levels, ranging from too high (hyperglycemia) to too low (hypoglycemia).

Some experts regard brittle diabetes as a subtype of type 1 diabetes, while others believe it's a complication of the disease. Sometimes, brittle diabetes is associated with stress and other psychological issues. It may require hospitalization.

This article takes a closer look at the causes and symptoms of brittle diabetes along with how it is treated, how it is diagnosed, and ways to cope with the disease.

The doctor checks at the diabetic a level of sugar in blood
Anetta_R / Getty Images

Brittle Diabetes Symptoms

The hallmark of brittle diabetes is frequent, unpredictable shifts in blood sugar levels, causing fluctuating symptoms of hyperglycemia and hypoglycemia.

Extreme swings in blood sugar due to brittle diabetes can negatively affect quality of life and require frequent hospitalization.

Symptoms of high blood sugar include:

  • Fatigue
  • Blurry vision
  • Excessive thirst
  • Increased hunger
  • Increased urination
  • Fruity breath
  • Nausea and vomiting

Symptoms of low blood sugar include:

  • Confusion
  • Lack of energy, fatigue, tiredness
  • Dizziness
  • Headache
  • Sweating
  • Feeling shaky or anxious
  • Increased heartbeat

Brittle diabetes is also marked by an increased risk of diabetic ketoacidosis (DKA), in which abnormally high levels of ketones build up in the blood.

DKA occurs when glucose, which your body uses for energy, is in short supply. As a result, your body breaks down fats to use for fuel instead. Ketones are acids that your liver produces as a byproduct of fat breakdown.

Ketoacidosis can rapidly lead to diabetic coma and even death. Symptoms of DKA include:

  • Excessive thirst
  • Increased urination
  • Lack of energy, fatigue
  • Fruity breath
  • Dry or flushed skin
  • Confusion
  • Nausea or vomiting

Ketoacidosis can be confirmed by testing the urine for ketone levels.

Vomiting is a sign that DKA may develop into a life-threatening condition in just a few hours. If you or a loved one are showing signs of DKA, seek immediate medical help.

Causes of Brittle Diabetes

Brittle diabetes may be caused by several factors, including health conditions or psychological issues such as depression or stress. Stress can bring on acute, temporary insulin resistance, in which the body will not respond as well to insulin, making it hard to predict your dosage.

Brittle diabetes may also be caused by altered digestion as a result of conditions such as celiac disease or malabsorption.

Autonomic neuropathy is a complication of diabetes that can lead to brittle diabetes. Autonomic neuropathy can compromise the digestive processes that metabolize glucose and affect stomach and intestine function. This makes it difficult to judge how much insulin to take.

Brittle Diabetes Risk Factors

Brittle diabetes is most likely to develop in those ages 15 to 30. Some studies suggest females are more likely to be affected than males. The primary risk factor is type 1 diabetes.

Other risk factors for brittle diabetes include:

  • Eating disorders, such as bulimia
  • Gastroparesis (gastrointestinal absorption problems, including delayed stomach emptying)
  • Drug interactions
  • Problems with insulin absorption
  • Hormonal malfunction
  • Hypothyroidism
  • Adrenal insufficiency, also known as Addison's disease

How Is Brittle Diabetes Diagnosed?

Identifying brittle diabetes can be tricky, as there are no specific metrics for diagnosis. Technically, the term "brittle diabetes" is a descriptive term—not an officially recognized form of diabetes.

Because of the lack of precision in the term, some healthcare providers diagnose the phenomenon as high glucose variability, simply meaning that the person experiences large swings in glucose levels.

Factors your healthcare provider will look for when checking your glucose variability include:

  • How severely your fasting glucose levels swing in a day
  • How many glucose swings you have per day
  • How much glucose is excreted in your urine per day
  • How frequently your urine tests positive for ketones
  • How frequently you experience unexpected hypoglycemia

Whether your provider calls it high glucose variability or brittle diabetes, the diagnosis is followed by the same goal: to treat the underlying issue and any complications, including DKA or severe hypoglycemia.

Brittle Diabetes Treatment

People with brittle diabetes may stop following a healthy diet or adequately managing their blood sugar. As blood sugar control wanes, metabolic imbalances further complicate and often worsen the underlying physical and psychological problems. This can lead to a repetitive cycle of glucose instability.

Balancing blood glucose levels to avoid erratic swings is the most effective way to treat brittle diabetes. Treatment may require a hospital stay of a few weeks with intensive monitoring of food, glucose, and insulin to restore glucose control.

In some cases, transferring to a different diabetes care team can serve as a helpful fresh start. Switching to a specialty diabetes center may help break the cycle of brittle diabetes.

Continuous glucose monitors and insulin pumps can be useful in the ongoing management of hypoglycemia and hyperglycemia. Technologies such as an artificial pancreas may also be helpful.

Continuous Glucose Monitors and Insulin Pumps

The more information you have regarding your blood sugar levels, the better you can manage your medications and reduce the frequency of blood glucose variability. For many people with type 1 diabetes, this may mean wearing a continuous glucose monitor and using an insulin pump. 

Continuous glucose monitors can alert you to dips or spikes in your blood sugar so you can take the necessary steps to get it under control. Some come equipped with safety alerts and alarms to notify you of rising or dropping levels before they get too serious.

Insulin pumps can make insulin dosing more precise. They aim to mimic the normal functioning of the pancreas by delivering a small amount of basal insulin throughout the day to cover the body's needs. They also deliver larger doses (bolus insulin) each time you eat a meal or snack.

Psychological Treatment

Sometimes, an underlying psychological condition may be at play if your glucose levels respond normally to diabetes drugs and there are no other uncontrolled health conditions. If that's the case, psychological treatment may help.

It's helpful to consult a psychology professional for evaluation. Treatment may involve exploring the cause of your stress and trying a variety of methods to lessen it. Psychotherapy has proven to be particularly effective in the long-term treatment of diabetes.

Medication for the treatment of anxiety or depression may help, although some drugs may interact with diabetes medications. Beta-blockers and some mood stabilizers, for example, may worsen diabetes symptoms, and others may affect how diabetes medications act in your body.

Transplantation

A pancreas transplant or an islet cell transplantation can be an option for some people who have type 1 diabetes.

Allotransplantation, a type of islet cell transplantation, is used for a select population of people with type 1 diabetes who have a difficult time managing their blood sugar or have hypoglycemia unawareness.

Transplants are only performed in clinical research hospitals that have received approval from the U.S. Food and Drug Administration (FDA).

New Technologies

Two models of an artificial pancreas have been approved by the FDA. This is a device that essentially serves to act as a human pancreas by automating insulin dosages in response to a rise in glucose levels,

Both models use hybrid closed-loop technology that automates insulin release, meaning users only need to adjust insulin levels at meals.

These systems can help take some of the guesswork out of insulin adjustments because they happen automatically.

Coping With Brittle Diabetes

People with brittle diabetes are frequently hospitalized, regularly miss work, and often have to contend with psychological problems. All these factors place additional emotional and financial stress on family members.

Many people find that working with a holistically-minded care team to employ stress reduction practices is helpful, both as a treatment for brittle diabetes and a means to cope with it.

Daily practices to consider include meditation, deep breathing, gentle yoga, and acupuncture. These practices may be used alongside psychotherapy and medication as needed.

It's important to reach out to your medical team for support for yourself and your family members.

Summary

Brittle diabetes, also called unstable diabetes, is uncontrolled diabetes characterized by frequent, severe swings in blood sugar. Brittle diabetes is caused by conditions that compromise one's ability to control their blood sugar. Stress, celiac disease, and autonomic neuropathy are three such conditions.

Brittle diabetes is closely linked to mental health. When a psychological condition underlines brittle diabetes, your provider may recommend a combination of psychotherapy and medical treatment, such as a continuous glucose monitor, to get your blood sugar under control.

12 Sources
Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
  1. National Institutes of Health. Genetic and rare diseases information center: Brittle diabetes.

  2. American Diabetes Association. Diabetes & DKA (ketoacidosis).

  3. Newman C, Dinneen SF. Brittle diabetes revisited: A description of erratic and difficult-to-control diabetes in an elderly woman with Type 1 diabetes. Diabet Med. 2019. doi:10.1111/dme.13972

  4. Centers for Disease Control and Prevention. Diabetic ketoacidosis.

  5. Thewjitcharoen Y, Viriyautsahakul V, Sasijaroenrat N, et al. Celiac disease as a cause of anemia and brittle diabetes in type 1 diabetes mellitus. J ASEAN Fed Endocr Soc. 2021 Oct;36(2):227-230. doi:10.15605/jafes.036.02.19

  6. Hirsch I, Gaudini L. A new look at brittle diabetes. JDC. 2021 Jan;35(1):1-8. doi:10.1016/j.jdiacomp.2020.107646

  7. Liu J, Zhou L, Sun L, et al. Association between intestinal Prevotella copri abundance and glycemic fluctuation in patients with brittle diabetes. Diabetes Metabol Syndr Obes. 2023 Jun;2023(16):1613-1621. doi:10.2147/DMSO.S412872

  8. National Institutes of Health. Genetic and rare diseases information center: Brittle diabetes.

  9. Harvey JN. Psychosocial interventions for the diabetic patientDiabetes Metab Syndr Obes. 2015;8:29-43. Published 2015 Jan 9. doi:10.2147/DMSO.S44352

  10. National Institute of Mental Health. Mental health medications.

  11. Singh Kochar I, Jain R. Pancreas transplant in type 1 diabetes mellitus: The emerging role of islet cell transplant. Ann Pediatr Endocrinol Metab. 2021 Jun;26(2):86-91. doi:10.6065/apem.2142012.006

  12. National Institute of Diabetes and Digestive and Kidney Diseases. Pancreatic islet transplantation. Updated October 2018.

By Heather M. Ross
Heather M. Ross, PhD, DNP, FAANP is a nurse practitioner and PhD in Human and Social Dimensions of Science and Technology.