Page 102 - JSOM Summer 2023

the bloodstream via the kidneys causing glucose to be excreted The term “brittle diabetes” was first described by Woddyatt in
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through the urinary system. He switched to metformin in an 1934 to describe individuals with large, unexplained changes
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attempt to return to duty without deployment-limiting medi- in blood glucose concentrations. Since then, many attempts
cations. He completed the U.S. Army Special Operations Com- have been made to describe the medical, psychological, and
mand (USASOC) physical fitness test to standard, including a social determinants of health contributing to the diverse group
5-mile run in less than 40 minutes and a 6-mile ruck in less of individuals with unstable or brittle diabetes. This case falls
than a 15 minute per mile pace. He stopped during both events into the second of four groups described by Hirsch et al., in-
due to symptoms of hypoglycemia and self-treated with oral cluding individuals who have a “medical condition resulting
glucose but still completed the events to standard. in major disruption of insulin sensitivity/utilization or a nutri-
tional disease-causing insulin-glucose mismatch.” 4
Continuous glucose monitor readings during this attempt to
return to full duty demonstrated that metformin alone could Listed medical etiologies of brittle diabetes include endocrinop-
not adequately control his blood glucoses with frequent epi- athies (thyrotoxicosis, acromegaly, Cushing’s syndrome, gluca-
sodes of hyperglycemia (>250mg/dL). There was no established gonoma, pheochromocytoma), systemic infection, stiff-person
correlation of blood glucose elevations with patterns of pre- syndrome, diabetic gastroparesis, lipodystrophy, insulin recep-
scribed exercise. He discontinued metformin and reverted to tor antibodies, Addison disease, celiac disease, renal failure,
the SGLT-2 inhibitor with the addition of basal insulin. He con- insulin or food insecurity, steroid dependence, and drug or
tinued to have wide variability in his blood glucoses that were alcohol addiction. Of the causes of severe glucose variability
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discordant with his A1c and not predictably related to exercise. caused by co-existing medical conditions, Type 3c DM is such
Serum fructose levels were ordered and were also discordant a rarity that it is not listed as an etiology by Hirsch et al. This
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with serum blood glucoses. His last HbA1c was 11.4%, and is the first case report of brittle diabetes associated with Type
he transitioned to insulin glargine and insulin aspart. Due to 3c DM.
his unpredictable fluctuations in endogenous insulin secretion,
the patient was diagnosed with brittle diabetes associated with Available literature recommends individualized glycemic man-
his Type 3c DM. A Medical Evaluation Board (MEB) was initi- agement strategies for Type 3c DM based on the degree of
ated due to his diagnosis and insulin requirement. A multidisci- exocrine pancreatic dysfunction and the underlying etiology of
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plinary medical team will attempt to utilize an insulin pump to the pancreatic dysfunction. Level C expert opinion evidence
safely manage his glycemia in the near future. suggests oral agents for glycemic control in Type 3c DM may
be appropriate, and metformin is specifically recommended
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Timeline to decrease the risk of pancreatic ductal adenocarcinoma.
January 2021: Deployed There are no case reports describing the efficacy or HbA1c
February: Hospitalized levels in cases in which oral agents were utilized. Thus, this
March–May: Outpatient multidisciplinary guided recovery is the first case report to describe the attempted use of oral
June: Symptom onset. Started on insulin. Tested for Type 1 glycemic agents for initial treatment of Type 3c diabetes in an
DM, diagnosed with Type 3c DM. athlete.
July: Continued on insulin glargine 20 units subcutaneous
every evening, insulin aspart 5 units subcutaneous every Oral medications are ideal for military Servicemembers to
morning. Continuous glucose monitor. minimize duty and deployment restrictions. Per Army Regula-
September: Started on empagliflozin. tion (AR) 40-501, all Soldiers should be deployable within 72
October: Insulin and empagliflozin discontinued. Started on hours, and Soldiers must undergo a medical evaluation board
metformin. (MEB) for retention if they require medications requiring fre-
November: Continued on metformin with onset of random quent monitoring. AR 40-501 further clarifies that Soldiers
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hyperglycemia (>250mg/dL). require an MEB with a diagnosis of diabetes. Though the reg-
December: Metformin discontinued. Restarted on empagli- ulation does not specify Type 3 Diabetes, it does state that “all
flozin and then insulin glargine 9 units. cases with HbA1c greater than 7.0% despite lifestyle modifi-
Follow-up: HbA1c 11.4%. Discordant glucose readings, A1c, cation for six months, intolerance, or declination of medical
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and fructose. Diagnosed with brittle diabetes. therapy” require a MEB. In the U.S. Army, a single episode
of acute pancreatitis meets retention criteria per Army Regu-
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lation 40-501. Therefore, the initial management goal in this
Discussion
case was to control the patient’s blood glucose with metformin
Type 3c DM is a rare condition, accounting for an estimated while he conducted a supervised return to physical activity,
0.5–1% of all cases of DM and 5–10% of adult cases of DM working up to the high-intensity requirements of a Special Op-
in the U.S. It is defined as DM due to pancreas insufficiency, erations Soldier.
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either in the form of disease or trauma. There are no case
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reports of athletes with Type 3c DM, and thus no clinical prac- The patient’s large blood glucose fluctuations secondary to his
tice guidelines available to guide the glucose and insulin man- diagnosis of brittle diabetes provide a challenge to his contin-
agement in athletes with Type 3c DM. The majority of cases uous blood glucose monitor in giving accurate readings. Ad-
(79%) of Type 3c DM stem from chronic pancreatitis, with ditionally, his glucose monitor readings have been persistently
no reports of acute idiopathic pancreatitis. Common causes of discordant with his HbA1c and fructose laboratory values. As
acute pancreatitis include gallstones, alcohol abuse, infection, a Special Operations Soldier, a unique challenge also includes
and trauma. However, we have no indications of any of the finding an insulin infusion device that meets operational secu-
aforementioned causes in this case. Furthermore, this leads to rity requirements, given that most devices require Bluetooth
the diagnosis of acute idiopathic necrotizing pancreatitis and capability. It is the goal of his medical team to conduct a safety
the first reported case associated with Type 3c DM. trial for an insulin infusion device in the future.

100 | JSOM Volume 23, Edition 2 / Summer 2023