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Gad H, Elgassim E, Mohammed I, Alhaddad AY, Ahmed Hussein Zaky Aly H, Cabibihan JJ, Al-Ali A, Sadasivuni KK, Haji A, Lamine N, Khan A, Petropoulos IN, Ponirakis G, Kalteniece A, Ferdousi M, Azmi S, Alam U, Abuhelaiqa W, Jayyousi A, AlMohanadi D, Baagar K, Malik RA. Continuous glucose monitoring reveals a novel association between duration and severity of hypoglycemia, and small nerve fiber injury in patients with diabetes. Endocr Connect 2022; 11:e220352. [PMID: 36240043 PMCID: PMC9716363 DOI: 10.1530/ec-22-0352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 10/14/2022] [Indexed: 11/08/2022]
Abstract
Objective Continuous glucose monitoring (CGM) has revealed that glycemic variability and low time in range are associated with albuminuria and retinopathy. We have investigated the relationship between glucose metrics derived from CGM and a highly sensitive measure of neuropathy using corneal confocal microscopy in participants with type 1 and type 2 diabetes. Methods A total of 40 participants with diabetes and 28 healthy controls underwent quantification of corneal nerve fiber density (CNFD), corneal nerve branch density (CNBD), corneal nerve fiber length (CNFL) and inferior whorl length (IWL) and those with diabetes underwent CGM for four consecutive days. Results CNBD was significantly lower in patients with high glycemic variability (GV) compared to low GV (median (range) (25.0 (19.0-37.5) vs 38.6 (29.2-46.9); P = 0.007); in patients who spent >4% compared to <4% time in level 1 hypoglycemia (54-69 mg/dL) (25.0 (22.9-37.5) vs 37.5 (29.2-46.9); P = 0.045) and in patients who spent >1% compared to <1% time in level 2 hypoglycemia (<54 mg/dL) (25.0 (19.8-41.7) vs 35.4 (28.1-44.8); P = 0.04). Duration in level 1 hypoglycemia correlated with CNBD (r = -0.342, P = 0.031). Duration in level 1 (181-250 mg/dL) and level 2 (>250 mg/dL) hyperglycemia did not correlate with CNFD (P > 0.05), CNBD (P > 0.05), CNFL (P > 0.05) or IWL (P > 0.05). Conclusions Greater GV and duration in hypoglycemia, rather than hyperglycemia, are associated with nerve fiber loss in diabetes.
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Affiliation(s)
- Hoda Gad
- Department of Medicine, Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Einas Elgassim
- Department of Medicine, Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Ibrahim Mohammed
- Department of Medicine, Weill Cornell Medicine-Qatar, Doha, Qatar
- Department of Internal Medicine, Albany Medical Center Hospital, Albany, New York, USA
| | - Ahmad Yaser Alhaddad
- Department of Mechanical and Industrial Engineering, Qatar University, Doha, Qatar
| | | | - John-John Cabibihan
- Department of Mechanical and Industrial Engineering, Qatar University, Doha, Qatar
| | - Abdulaziz Al-Ali
- KINDI Center for computing research, Qatar University, Doha, Qatar
| | | | - Aliyaa Haji
- Department of Medicine, Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Neila Lamine
- Department of Medicine, Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Adnan Khan
- Faculty of Healthy Sciences, Khyber Medical University, Peshawar, Pakistan
| | | | | | - Alise Kalteniece
- Institute of Cardiovascular Medicine, University of Manchester, Manchester, UK
| | - Maryam Ferdousi
- Institute of Cardiovascular Medicine, University of Manchester, Manchester, UK
| | - Shazli Azmi
- Institute of Cardiovascular Medicine, University of Manchester, Manchester, UK
| | - Uazman Alam
- Diabetes and Neuropathy Research, Department of Eye and Vision Sciences and Pain Research Institute, Institute of Ageing and Chronic Disease, University of Liverpool and Aintree University Hospital NHS Foundation Trust, Liverpool, UK
- Department of Diabetes and Endocrinology, Royal Liverpool and Broadgreen University NHS Hospital Trust, Liverpool, UK
- Division of Endocrinology, Diabetes and Gastroenterology, University of Manchester, Manchester, UK
| | | | - Amin Jayyousi
- Hamad Medical Corporation, National Diabetes Center, Doha, Qatar
| | - Dabia AlMohanadi
- Hamad Medical Corporation, National Diabetes Center, Doha, Qatar
| | - Khaled Baagar
- Hamad Medical Corporation, National Diabetes Center, Doha, Qatar
| | - Rayaz A Malik
- Department of Medicine, Weill Cornell Medicine-Qatar, Doha, Qatar
- Institute of Cardiovascular Medicine, University of Manchester, Manchester, UK
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New Insight on Insulinoma Treatment in a Pet Rat-A Case Report. Animals (Basel) 2022; 12:ani12202783. [PMID: 36290169 PMCID: PMC9597777 DOI: 10.3390/ani12202783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 10/05/2022] [Accepted: 10/13/2022] [Indexed: 11/07/2022] Open
Abstract
Simple Summary Insulinomas are tumors of the pancreas that cause hypoglycemia. They have high prevalence in ferrets, whereas in rats are a much rare finding. The available literature on spontaneous insulinomas in rats is currently scarce. The patient from our case report was presented with no obvious hypoglycemic signs, only progressive weakness of the hind limbs was noted. However, a blood exam revealed low blood glucose and a mass in the pancreas was found on the abdominal ultrasound. The patient responded well to treatment with oral dexamethasone and survived nearly 4 months in good general condition. In geriatric rats peripheral neuropathy and pituitary tumors are very common, leading to mobility disfunction. That is why insulinoma should always be considered in cases of neurological deficits in these patients. Abstract Insulinomas are insulin-producing tumors of pancreatic beta cells that cause hypoglycemia. They are extremely common in ferrets but have also been reported in guinea pigs and rats. This is a case report of an older rat with spontaneous insulinoma, which was confirmed by histopathology. The patient was presented at a regular check-up due to a chronic respiratory disease. The owner noticed progressive weakness of the hind limbs, which is quite commonly seen in older rats. A blood exam revealed hypoglycemia, which could have been associated with paraparesis. The patient responded to treatment with oral dexamethasone and was regularly monitored. It survived nearly 4 months in good general condition. The rat finally died most probably due to severe hypoglycemia caused by progression of the pancreatic tumor. This is the first report of a pet rat with insulinoma that was successfully treated with glucocorticoids.
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Siddique N, Durcan R, Smyth S, Tun TK, Sreenan S, McDermott JH. Acute diabetic neuropathy following improved glycaemic control: a case series and review. Endocrinol Diabetes Metab Case Rep 2020; 2020:EDM190140. [PMID: 32101524 PMCID: PMC7077599 DOI: 10.1530/edm-19-0140] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 01/14/2020] [Indexed: 11/08/2022] Open
Abstract
SUMMARY We present three cases of acute diabetic neuropathy and highlight a potentially underappreciated link between tightening of glycaemic control and acute neuropathies in patients with diabetes. Case 1: A 56-year-old male with poorly controlled type 2 diabetes (T2DM) was commenced on basal-bolus insulin. He presented 6 weeks later with a diffuse painful sensory neuropathy and postural hypotension. He was diagnosed with treatment-induced neuropathy (TIN, insulin neuritis) and obtained symptomatic relief from pregabalin. Case 2: A 67-year-old male with T2DM and chronic hyperglycaemia presented with left lower limb pain, weakness and weight loss shortly after achieving target glycaemia with oral anti-hyperglycaemics. Neurological examination and neuro-electrophysiological studies suggested diabetic lumbosacral radiculo-plexus neuropathy (DLPRN, diabetic amyotrophy). Pain and weakness resolved over time. Case 3: A 58-year-old male was admitted with blurred vision diplopia and complete ptosis of the right eye, with intact pupillary reflexes, shortly after intensification of glucose-lowering treatment with an SGLT2 inhibitor as adjunct to metformin. He was diagnosed with a pupil-sparing third nerve palsy secondary to diabetic mononeuritis which improved over time. While all three acute neuropathies have been previously well described, all are rare and require a high index of clinical suspicion as they are essentially a diagnosis of exclusion. Interestingly, all three of our cases are linked by the development of acute neuropathy following a significant improvement in glycaemic control. This phenomenon is well described in TIN, but not previously highlighted in other acute neuropathies. LEARNING POINTS A link between acute tightening of glycaemic control and acute neuropathies has not been well described in literature. Clinicians caring for patients with diabetes who develop otherwise unexplained neurologic symptoms following a tightening of glycaemic control should consider the possibility of an acute diabetic neuropathy. Early recognition of these neuropathies can obviate the need for detailed and expensive investigations and allow for early institution of appropriate pain-relieving medications.
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Affiliation(s)
- N Siddique
- Departments of Diabetes and EndocrinologyConnolly Hospital Blanchardstown, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - R Durcan
- Departments of Diabetes and EndocrinologyConnolly Hospital Blanchardstown, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - S Smyth
- Department of NeurologyMater Misericordiae University Hospital, Dublin, Ireland
| | - T Kyaw Tun
- Departments of Diabetes and EndocrinologyConnolly Hospital Blanchardstown, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - S Sreenan
- Departments of Diabetes and EndocrinologyConnolly Hospital Blanchardstown, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - J H McDermott
- Departments of Diabetes and EndocrinologyConnolly Hospital Blanchardstown, Royal College of Surgeons in Ireland, Dublin, Ireland
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Chandler E, Brown M, Wintergerst K, Doll E. Treatment-Induced Neuropathy of Diabetes (TIND) in Pediatrics: A Case Report and Review of the Literature. J Clin Endocrinol Metab 2020; 105:5587829. [PMID: 31613321 DOI: 10.1210/clinem/dgz067] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 10/03/2019] [Indexed: 02/13/2023]
Abstract
CONTEXT Treatment-induced neuropathy of diabetes (TIND) is a rarely reported but important consideration in patients presenting with an acute onset of neuropathic symptoms following rapid correction of hyperglycemia in diabetes. Although it has been reported in children, the preponderance of literature focuses on adults with TIND. CASE DESCRIPTION We report an 18-year-old male with this condition and his clinical course. We then discuss the proposed pathophysiology of TIND and review the literature. We also provide a standard workup for the diagnosis of TIND. CONCLUSION In both pediatric and adult populations, TIND should be considered in diabetic patients who develop neuropathy acutely following rapid correction of hyperglycemia. Because the pathophysiology of TIND remains poorly understood, there is insufficient information regarding how to target susceptible individuals and prevent the development of TIND.
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Affiliation(s)
- Erika Chandler
- Department of Neurology, Division of Child Neurology, University of Louisville, Louisville, Kentucky
| | - Martin Brown
- Department of Neurology, University of Louisville School of Medicine, Louisville, Kentucky
| | - Kupper Wintergerst
- Department of Pediatrics, Division of Pediatric Endocrinology, University of Louisville School of Medicine, Louisville, Kentucky
| | - Elizabeth Doll
- Department of Neurology, Division of Child Neurology, University of Louisville, Louisville, Kentucky
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Dysglycemia and Neurologic Outcome in Mechanically Ventilated Patients With Guillain-Barré Syndrome. Crit Care Med 2019; 47:e227-e233. [DOI: 10.1097/ccm.0000000000003635] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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Fesseha BK, Abularrage CJ, Hines KF, Sherman R, Frost P, Langan S, Canner J, Likes KC, Hosseini SM, Jack G, Hicks CW, Yalamanchi S, Mathioudakis N. Association of Hemoglobin A 1c and Wound Healing in Diabetic Foot Ulcers. Diabetes Care 2018; 41:1478-1485. [PMID: 29661917 PMCID: PMC6014539 DOI: 10.2337/dc17-1683] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Accepted: 03/26/2018] [Indexed: 02/06/2023]
Abstract
OBJECTIVE This study evaluated the association between hemoglobin A1c (A1C) and wound outcomes in patients with diabetic foot ulcers (DFUs). RESEARCH DESIGN AND METHODS We conducted a retrospective analysis of an ongoing prospective, clinic-based study of patients with DFUs treated at an academic institution during a 4.7-year period. Data from 270 participants and 584 wounds were included in the analysis. Cox proportional hazards regression was used to assess the incidence of wound healing at any follow-up time in relation to categories of baseline A1C and the incidence of long-term (≥90 days) wound healing in relation to tertiles of nadir A1C change and mean A1C change from baseline, adjusted for potential confounders. RESULTS Baseline A1C was not associated with wound healing in univariate or fully adjusted models. Compared with a nadir A1C change from baseline of -0.29 to 0.0 (tertile 2), a nadir A1C change of 0.09 to 2.4 (tertile 3) was positively associated with long-term wound healing in the subset of participants with baseline A1C <7.5% (hazard ratio [HR] 2.07; 95% CI 1.08-4.00), but no association with wound healing was seen with the mean A1C change from baseline in this group. Neither nadir A1C change nor mean A1C change were associated with long-term wound healing in participants with baseline A1C ≥7.5%. CONCLUSIONS There does not appear to be a clinically meaningful association between baseline or prospective A1C and wound healing in patients with DFUs. The paradoxical finding of accelerated wound healing and increase in A1C in participants with better baseline glycemic control requires confirmation in further studies.
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Affiliation(s)
- Betiel K Fesseha
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - Christopher J Abularrage
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Johns Hopkins University, Baltimore, MD
| | - Kathryn F Hines
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Johns Hopkins University, Baltimore, MD
| | - Ronald Sherman
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Johns Hopkins University, Baltimore, MD
| | - Priscilla Frost
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Johns Hopkins University, Baltimore, MD
| | - Susan Langan
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - Joseph Canner
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Johns Hopkins University, Baltimore, MD
| | - Kendall C Likes
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Johns Hopkins University, Baltimore, MD
| | - Sayed M Hosseini
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - Gwendolyne Jack
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - Caitlin W Hicks
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Johns Hopkins University, Baltimore, MD
| | - Swaytha Yalamanchi
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - Nestoras Mathioudakis
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Johns Hopkins University, Baltimore, MD
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Packer M. Have we really demonstrated the cardiovascular safety of anti-hyperglycaemic drugs? Rethinking the concepts of macrovascular and microvascular disease in type 2 diabetes. Diabetes Obes Metab 2018; 20:1089-1095. [PMID: 29316137 DOI: 10.1111/dom.13207] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Revised: 12/12/2017] [Accepted: 12/22/2017] [Indexed: 02/06/2023]
Abstract
A primary goal of the treatment of type 2 mellitus is the prevention of morbidity and mortality associated with cardiovascular disease; however, anti-hyperglycaemic drugs have the capacity to cause deleterious effects on the circulation, a risk that is not adequately reflected by the endpoints selected for emphasis in large-scale clinical trials that are designed to evaluate cardiovascular safety. The primary endpoint of the large-scale studies mandated by regulatory authorities focuses only on 3 to 4 events that depict only a limited view of the circulatory system. One of the most serious adverse effects of many glucose-lowering drugs is new-onset or worsening heart failure. Most antidiabetic drugs can aggravate heart failure because they exert anti-natriuretic actions, and possibly, adverse effects on the myocardium. In addition, certain anti-hyperglycaemic agents may worsen peripheral vascular disease and trigger cardiac arrhythmias that may lead to sudden death. Initiation of treatment with antidiabetic medications may also cause deterioration of the function of the kidneys, retina and peripheral nerves, which are typically regarded as reflecting microvascular disease. The current confusion about the cardiovascular effects of glucose-lowering drugs may be exacerbated by conceptual uncertainties about the classification of large and small vessel disease in determining the clinical course of diabetes. Physicians should not be falsely reassured by claims that a new treatment appears to have passed a narrowly defined regulatory test. The management of people with diabetes often carries with it the risk of important cardiovascular consequences, even for drugs that do not overtly increase the risk of myocardial infarction or stroke.
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Affiliation(s)
- Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, Texas
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Bartels T, Wäse K, Heinrichs M, Stolte M, Roome N, Scherer P, Lindauer K. Regulatory Forum Opinion Piece: Review-Toxicological Pathology Profile and Regulatory Expectations for Nonclinical Development of Insulins and Insulin Analogues. Toxicol Pathol 2017; 44:931-46. [PMID: 27663844 DOI: 10.1177/0192623316665721] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The toxicological profile of insulins is exclusively due to exaggerated pharmacology resulting in hypoglycemic findings. Insulin analogues displaying modifications and aimed at improving pharmacokinetics do not induce different toxicity. The main target is the brain displaying neuronal necrosis. Wallerian degeneration of nerves occurs rarely after severe hypoglycemia. These findings are of potential human relevance; nevertheless, these changes are induced in normoglycemic animals whereas diabetic patients suffer from hyperglycemia. Therefore, it is usually not difficult to achieve a therapeutic window for subsequent use in patients. Based upon this and in the absence of classical toxicity, there has been no scientific need for diabetic animal models. A greater challenge is the mitogenicity already inherent with regular insulin. Thus, the focus for preclinical safety evaluation of analogues is to demonstrate that modifications in regular insulin do not result in enhanced mitogenicity. The approaches used to assess the mitogenic potential of insulin analogues have changed over time driven by scientific progression and changes within the regulatory environment. Therefore, in vitro and in vivo evaluation of cell proliferation has become common practice, and to date there has been no evidence that the mitogenic potential of insulin analogues may be increased compared to regular insulin.
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Affiliation(s)
| | | | | | | | - Nigel Roome
- Consultant in Toxicology and Toxicologic Pathology, Versailles, France
| | - Petra Scherer
- Sanofi, Animal Research and Welfare, Frankfurt, Germany
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Abstract
Diabetes mellitus is the commonest cause of an autonomic neuropathy in the developed world. Diabetic autonomic neuropathy causes a constellation of symptoms and signs affecting cardiovascular, urogenital, gastrointestinal, pupillomotor, thermoregulatory, and sudomotor systems. Several discrete syndromes associated with diabetes cause autonomic dysfunction. The most prevalent of these are: generalized diabetic autonomic neuropathy, autonomic neuropathy associated with the prediabetic state, treatment-induced painful and autonomic neuropathy, and transient hypoglycemia-associated autonomic neuropathy. These autonomic manifestations of diabetes are responsible for the most troublesome and disabling features of diabetic peripheral neuropathy and result in a significant proportion of the mortality and morbidity associated with the disease.
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Affiliation(s)
- Roy Freeman
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
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[Diabetic neuropathy: do not only consider distal symmetrical neuropathy]. DER NERVENARZT 2015; 86:161-6. [PMID: 25604836 DOI: 10.1007/s00115-014-4127-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Diabetic neuropathy is a common complication of diabetes mellitus. The length-dependent symmetrical sensorimotor type of neuropathy is the most prevalent form of diabetic neuropathy but other forms of diabetic neuropathy also need to be kept in mind. Their differential diagnosis is often more challenging but implicates specific forms of treatment other than improvement of metabolic control. AIM OF THE STUDY This article gives an overview of the less frequent forms of diabetic neuropathy and discusses their impact, diagnostic and therapeutic implications. RESULTS Autonomic diabetic neuropathy, diabetic small fiber neuropathy and less frequent forms of diabetic neuropathy, such as diabetic radiculoplexopathy, diabetic neuropathy of cranial nerves, therapy-induced neuropathy and alternative causes of peripheral neuropathy in patients with diabetes are described. DISCUSSION Diagnosis of less frequent subtypes of diabetic neuropathy and differentiation towards alternative causes of peripheral neuropathy are often difficult in daily medical routine. Diagnostic clues are helpful in identifying rarer forms of diabetic neuropathy, thus enabling more specific treatment.
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Gibbons CH, Freeman R. Treatment-induced neuropathy of diabetes: an acute, iatrogenic complication of diabetes. Brain 2014; 138:43-52. [PMID: 25392197 DOI: 10.1093/brain/awu307] [Citation(s) in RCA: 133] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Treatment-induced neuropathy in diabetes (also referred to as insulin neuritis) is considered a rare iatrogenic small fibre neuropathy caused by an abrupt improvement in glycaemic control in the setting of chronic hyperglycaemia. The prevalence and risk factors of this disorder are not known. In a retrospective review of all individuals referred to a tertiary care diabetic neuropathy clinic over 5 years, we define the proportion of individuals that present with and the risk factors for development of treatment-induced neuropathy in diabetes. Nine hundred and fifty-four individuals were evaluated for a possible diabetic neuropathy. Treatment-induced neuropathy in diabetes was defined as the acute onset of neuropathic pain and/or autonomic dysfunction within 8 weeks of a large improvement in glycaemic control-specified as a decrease in glycosylated haemoglobin A1C (HbA1c) of ≥2% points over 3 months. Detailed structured neurologic examinations, glucose control logs, pain scores, autonomic symptoms and other microvascular complications were measured every 3-6 months for the duration of follow-up. Of 954 patients evaluated for diabetic neuropathy, 104/954 subjects (10.9%) met criteria for treatment-induced neuropathy in diabetes with an acute increase in neuropathic or autonomic symptoms or signs coinciding with a substantial decrease in HbA1c. Individuals with a decrease in HbA1c had a much greater risk of developing a painful or autonomic neuropathy than those individuals with no change in HbA1c (P < 0.001), but also had a higher risk of developing retinopathy (P < 0.001) and microalbuminuria (P < 0.001). There was a strong correlation between the magnitude of decrease in HbA1c, the severity of neuropathic pain (R = 0.84, P < 0.001), the degree of parasympathetic dysfunction (R = -0.52, P < 0.01) and impairment of sympathetic adrenergic function as measured by fall in blood pressure on tilt-table testing (R = -0.63, P < 0.001). With a decrease in HbA1c of 2-3% points over 3 months there was a 20% absolute risk of developing treatment-induced neuropathy in diabetes, with a decrease in HbA1c of >4% points over 3 months the absolute risk of developing treatment-induced neuropathy in diabetes exceeded 80%. Treatment-induced neuropathy of diabetes is an underestimated iatrogenic disorder associated with diffuse microvascular complications. Rapid glycaemic change in patients with uncontrolled diabetes increases the risk of this complication.
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Affiliation(s)
- Christopher H Gibbons
- Department of Neurology, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA, USA
| | - Roy Freeman
- Department of Neurology, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA, USA
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Jensen VFH, Mølck AM, Bøgh IB, Lykkesfeldt J. Effect of insulin-induced hypoglycaemia on the peripheral nervous system: focus on adaptive mechanisms, pathogenesis and histopathological changes. J Neuroendocrinol 2014; 26:482-96. [PMID: 24921897 DOI: 10.1111/jne.12170] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2014] [Revised: 05/22/2014] [Accepted: 06/05/2014] [Indexed: 12/31/2022]
Abstract
Insulin-induced hypoglycaemia (IIH) is a common acute side effect in type 1 and type 2 diabetic patients, especially during intensive insulin therapy. The peripheral nervous system (PNS) depends on glucose as its primary energy source during normoglycaemia and, consequently, it may be particularly susceptible to IIH damage. Possible mechanisms for adaption of the PNS to IIH include increased glucose uptake, utilisation of alternative energy substrates and the use of Schwann cell glycogen as a local glucose reserve. However, these potential adaptive mechanisms become insufficient when the hypoglycaemic state exceeds a certain level of severity and duration, resulting in a sensory-motor neuropathy with associated skeletal muscle atrophy. Large myelinated motor fibres appear to be particularly vulnerable. Thus, although the PNS is not an obligate glucose consumer, as is the brain, it appears to be more prone to IIH than the central nervous system when hypoglycaemia is not severe (blood glucose level ≤ 2 mm), possibly reflecting a preferential protection of the brain during periods of inadequate glucose availability. With a primary focus on evidence from experimental animal studies investigating nondiabetic IIH, the present review discusses the effect of IIH on the PNS with a focus on adaptive mechanisms, pathogenesis and histological changes.
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Affiliation(s)
- V F H Jensen
- Department of Veterinary Disease, Biology, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Department of Diabetes Toxicology and Safety Pharmacology, Novo Nordisk A/S, Maaloev, Denmark
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14
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Gibbons CH, Freeman R. Treatment-induced diabetic neuropathy: a reversible painful autonomic neuropathy. Ann Neurol 2010; 67:534-41. [PMID: 20437589 DOI: 10.1002/ana.21952] [Citation(s) in RCA: 122] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To describe the natural history, clinical, neurophysiological, and histological features, and outcomes of diabetic patients presenting with acute painful neuropathy associated with glycemic control, also referred to as insulin neuritis. METHODS Sixteen subjects presenting with acute painful neuropathy had neurological and retinal examinations, laboratory studies, autonomic testing, and pain assessments over 18 months. Eight subjects had skin biopsies for evaluation of intraepidermal nerve fiber density. RESULTS All subjects developed severe pain within 8 weeks of intensive glucose control. There was a high prevalence of autonomic cardiovascular, gastrointestinal, genitourinary, and sudomotor symptoms in all subjects. Orthostatic hypotension and parasympathetic dysfunction were seen in 69% of subjects. Retinopathy worsened in all subjects. Reduced intraepidermal nerve fiber density (IENFD) was seen in all tested subjects. After 18 months of glycemic control, there were substantial improvements in pain, autonomic symptoms, autonomic test results, and IENFD. Greater improvements were seen after 18 months in type 1 versus type 2 diabetic subjects in autonomic symptoms (cardiovascular p < 0.01; gastrointestinal p < 0.01; genitourinary p < 0.01) and autonomic function tests (p < 0.01, sympathetic and parasympathetic function tests). INTERPRETATION Treatment-induced neuropathy is characterized by acute, severe pain, peripheral nerve degeneration, and autonomic dysfunction after intensive glycemic control. The neuropathy occurred in parallel with worsening diabetic retinopathy, suggesting a common underlying pathophysiological mechanism. Clinical features and objective measures of small myelinated and unmyelinated nerve fibers can improve in these diabetic patients despite a prolonged history of poor glucose control, with greater improvement seen in patients with type 1 diabetes.
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Affiliation(s)
- Christopher H Gibbons
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA
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Dabby R, Sadeh M, Lampl Y, Gilad R, Watemberg N. Acute painful neuropathy induced by rapid correction of serum glucose levels in diabetic patients. Biomed Pharmacother 2008; 63:707-9. [PMID: 18848759 DOI: 10.1016/j.biopha.2008.08.011] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2008] [Accepted: 08/24/2008] [Indexed: 11/28/2022] Open
Abstract
We report on acute painful neuropathy following reduction of high serum glucose levels in six diabetic patients, aged 27-52 (5 males). Initial glucose levels ranging between 270 and 600 mg/dL decreased to 60-160 mg/dL following insulin, pharmacologic or dietary treatment. Four patients had long-standing untreated diabetes (3-5 years). All six patients experienced severe excruciating neuropathic pain 2-4 weeks after initiation of treatment. Pain was generalized in all, starting in the feet in 4 cases. Pain intensity prompted the use of combination therapy with various anti-neuropathic pain agents. Symptoms gradually improved in all patients, allowing discontinuation of symptomatic therapy within 3-8 months. We conclude that acute painful neuropathy can complicate the correction of high glucose levels in diabetic patients. Therefore, careful correction of glucose levels should be considered in patients with long-standing uncontrolled diabetes.
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Affiliation(s)
- Ron Dabby
- Department of Neurology, Wolfson Medical Center, 62 Halochamim Street, Holon 58100, Israel.
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Jamali R, Mohseni S. Differential neuropathies in hyperglycemic and hypoglycemic diabetic rats. J Neuropathol Exp Neurol 2007; 65:1118-25. [PMID: 17146285 DOI: 10.1097/01.jnen.0000248546.13176.d4] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
We investigated the effects of hyperglycemia and hypoglycemia on development of peripheral neuropathy in somatic motor and sensory nerves in type 1 diabetic BB/Wor rats. The animals were maintained in a hyper- or hypoglycemic state by treatment with insulin for 3 months. Nondiabetic siblings served as controls. Qualitative analysis of the gastrocnemius and sural nerves by light and electron microscopy revealed signs of Wallerian-type axonal degeneration and regeneration of large myelinated fibers in the hypoglycemic but not the hyperglycemic animals. Degeneration was more common in the gastrocnemius nerve than in the sural nerve. In hypoglycemic rats, myelinated fibers in both the gastrocnemius and sural nerves had significantly shorter internodes and smaller diameters. The decreased fiber diameter was related (r = -0.9) to the duration of severe hypoglycemia (</=2.5 mmol/L). Myelinated fiber occupancy was also decreased without any significant changes in fiber counts in both the gastrocnemius and sural nerves. In hyperglycemic rats, myelinated fibers in the sural nerve but not the gastrocnemius nerve had smaller diameters compared with controls. We conclude that hypoglycemia has a more severe impact on somatic motor nerves than on somatic sensory nerves, whereas hyperglycemia affects only somatic sensory nerves.
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Affiliation(s)
- Reza Jamali
- Division of Cell Biology, Department of Biomedicine and Surgery and Diabetic Research Centre, Faculty of Health Sciences, Linköping University, SE-581 85 Linköping, Sweden.
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Sugimoto K, Shoji M, Yasujima M, Suda T, Yagihashi S. Peripheral nerve endoneurial microangiopathy and necrosis in rats with insulinoma. Acta Neuropathol 2004; 108:503-14. [PMID: 15365726 DOI: 10.1007/s00401-004-0915-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2004] [Revised: 07/19/2004] [Accepted: 07/26/2004] [Indexed: 10/26/2022]
Abstract
Peripheral nerve pathology related to chronic hyperinsulinemia and hypoglycemia has yet to be fully explored. Here we conducted a systematic quantitative analysis of morphological alterations in peripheral sensory and motor nerve fibers and endoneurial microvasculature in longstanding insulinoma-carrying rats (I-rats; n=12). Age-matched normal rats (n=6) served as controls. Over the 15-month observation period, two of I-rats developed paresis of the hind limbs when their blood glucose level fell below 1.7 mmol/l. These animals showed a massive myelinated fiber loss associated with active degeneration of residual myelinated fibers and multiple endoneurial microvascular occlusions at the sciatic nerve level. The rest of the non-paretic I-rats showed a decreased density of large myelinated fibers with axonal degeneration in the peroneal nerve and an increased density of small myelinated fibers with preserved morphology in the sural nerve. This was associated with endoneurial microangiopathic changes indicative of endoneurial ischemia/hypoxia in the sciatic and peroneal nerves, and an increase in endoneurial microvascular density in the sciatic and sural nerves. In conjunction with previous data, these findings suggest that the observed increase in endoneurial microvascular density may be a compensatory response to endoneurial ischemia/hypoxia induced by chronic hyperinsulinemia in I-rats without paresis. In conclusion, the present study showed characteristic morphological alterations in peripheral sensory and motor nerve fibers associated with microangiopathy indicative of endoneurial ischemia/hypoxia in the sciatic and peroneal nerves, and provides the first evidence for the occurrence of endoneurial necrosis in the sciatic nerve, to which the hind limb paresis can be ascribed in I-rats.
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Affiliation(s)
- Kazuhiro Sugimoto
- Department of Laboratory Medicine, Hirosaki University School of Medicine, 5 Zaifu-cho, 036-8562 Hirosaki, Japan.
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Striano S, Striano P, Manganelli F, Boccella P, Bruno R, Santoro L, Percopo V. Distal hypoglycemic neuropathy. An insulinoma-associated case, misdiagnosed as temporal lobe epilepsy. Neurophysiol Clin 2003; 33:223-7. [PMID: 14672823 DOI: 10.1016/j.neucli.2003.08.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Peripheral distal neuropathy associated with hypoglycemia secondary to insulinoma is quite rare. So far, less than 40 cases have been reported in literature. In this report, we describe a 50-year-old patient with insulinoma-polineuropathy and neuropsychiatric symptoms, interpreted as temporal lobe epilepsy, over the preceding 7 years. Due to the variability of the clinical presentation, diagnostic mistakes are frequent, and diagnosis of insulinoma is often delayed. Thus, the hypoglycemic nature of neuropathy can be lately recognized.
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Affiliation(s)
- S Striano
- Department of Neurological Sciences, Epilepsy Center, "Federico II" University, Via Pansini 5, Naples 80131, Italy.
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Sugimoto K, Baba M, Suda T, Yasujima M, Yagihashi S. Peripheral neuropathy and microangiopathy in rats with insulinoma: association with chronic hyperinsulinemia. Diabetes Metab Res Rev 2003; 19:392-400. [PMID: 12951647 DOI: 10.1002/dmrr.395] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Hypoglycemia can precipitate or worsen peripheral neuropathy in patients with insulinoma or in diabetic patients on an intensive insulin regimen. It still remains unclear as to whether hyperinsulinemia itself is involved in neuropathic changes in these patients. We, therefore, explored the possible isolated effects of chronic hyperinsulinemia on neuropathic changes in insulinoma-bearing rats (I-rats). METHODS I-rats were generated by a combined treatment with nicotinamide and streptozotocin. At 15 months after the treatment, they showed a wide range of the plasma insulin (PI) level with or without a decrease in the blood glucose (BG) level and were divided into three groups on the basis of the presence of hypoglycemia (BG < 2.5 mmol/L) or hyperinsulinemia (PI > 100 mU/L): the first exhibited only hypoglycemia, the second exhibited only hyperinsulinemia, and the third exhibited neither. Peripheral nerve function and structure as well as microvasculature were evaluated among these groups in addition to age-matched untreated control rats (C-rats). RESULTS The first group of hypoglycemic I-rats showed a decrease (p < 0.05) in the axon/myelin ratio and an increase (p < 0.0001) in fibers undergoing axonal degeneration compared to C-rats, while the other two groups did not. On the other hand, the second group of hyperinsulinemic I-rats showed a decrease (p < 0.05) in the myelinated axonal size and an increase (all p < 0.05) in the F-wave latency and the densities of myelinated fibers and endoneurial microvessels exhibiting endothelial hyperplasia, vascular wall thickening, or pericytes debris compared to the third group of isoglycemic I-rats without hyperinsulinemia. CONCLUSION These results suggest that hypoglycemia is associated with increased myelinated axonal damage, while hyperinsulinemia is associated with increased densities of small myelinated axons and endoneurial microvessels with microangiopathic changes in I-rats. We, therefore, propose that the observed findings may be relevant to the complicated features of neuropathy in diabetic patients with chronic hyperinsulinemia.
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Affiliation(s)
- Kazuhiro Sugimoto
- Department of Laboratory Medicine, Hirosaki University School of Medicine, Hirosaki, Japan.
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