Schade D S, Burge M R
Department of Medicine, Endocrinology, University of New Mexico School of Medicine, Albuquerque, USA.
Adv Endocrinol Metab. 1995;6:289-319.
Brittle diabetes is an uncommon complication of type I diabetes. However, the seriousness of the complication and its demands on the health care system warrant aggressive intervention. Studies during the last decade demonstrate that brittle diabetes is always secondary to a specific, identifiable etiology. This etiology is rarely apparent, however, without both extensive metabolic and psychological testing. In the long term, this testing is cost-effective inasmuch as approximately 50% of brittle diabetic patients are amenable to specific therapy. Several important issues have been clarified during the last decade, during which time major attempts have been made to understand the etiology of brittle diabetes. These issues may be summarized as follows: 1. There is always a specific etiology causing the brittle diabetes. 2. There are many different causes of brittle diabetes, but the most common are psychological abnormalities. 3. Therapy should always be directed at correcting the underlying pathogenic factor(s). 4. Empirical therapy and invasive procedures are contraindicated in brittle diabetic patients. 5. Extensive evaluation of a brittle diabetic patient may require referral of the patient to a diabetes center that has the expertise and manpower to appropriately evaluate a brittle diabetic patient. 6. Close follow-up and continued evaluation of therapy are necessary to confirm the suspected etiology and prevent diabetic ketoacidosis from developing. Unfortunately, only 50% of brittle diabetic patients respond to specific etiologic treatment. Research efforts during the next decade will focus on several clinical problems. First, improved psychological interventions are needed for common causes such as manipulative behavior and factitious disease. Second, treatment of severe systemic insulin resistance is still a major therapeutic challenge. Third, impaired glucose counterregulation needs to be better understood so that treatment is possible. The ultimate goal for physicians caring for brittle diabetic patients is to have effective therapy for all causes of brittle diabetes.
脆性糖尿病是1型糖尿病的一种罕见并发症。然而，该并发症的严重性及其对医疗保健系统的要求需要积极干预。过去十年的研究表明，脆性糖尿病总是继发于特定的、可识别的病因。然而，如果没有广泛的代谢和心理测试，这种病因很少会显现出来。从长远来看，这种测试具有成本效益，因为大约50%的脆性糖尿病患者适合接受特定治疗。在过去十年中，几个重要问题已经得到澄清，在此期间人们主要致力于了解脆性糖尿病的病因。这些问题可总结如下：1. 总是存在导致脆性糖尿病的特定病因。2. 脆性糖尿病有许多不同的病因，但最常见的是心理异常。3. 治疗应始终针对纠正潜在的致病因素。4. 脆性糖尿病患者禁忌经验性治疗和侵入性操作。5. 对脆性糖尿病患者进行广泛评估可能需要将患者转诊至有专业知识和人力来适当评估脆性糖尿病患者的糖尿病中心。6. 密切随访和持续评估治疗对于确认疑似病因和预防糖尿病酮症酸中毒的发生是必要的。不幸的是，只有50%的脆性糖尿病患者对特定的病因治疗有反应。未来十年的研究工作将集中在几个临床问题上。首先，对于诸如操纵行为和人为性疾病等常见病因，需要改进心理干预措施。其次，治疗严重的全身性胰岛素抵抗仍然是一个主要的治疗挑战。第三，需要更好地理解葡萄糖反向调节受损，以便进行治疗。照顾脆性糖尿病患者的医生的最终目标是对所有导致脆性糖尿病的病因都有有效的治疗方法。
