血糖控制太快也可能出問題...

Treatment-Induced Diabetic Neuropathy
An unusual complication of rapid intensive glycemic control

In sporadic case reports — some published more than 50 years ago — clinicians have described acute severe painful neuropathy that can occur during intensive treatment of patients with poorly controlled diabetes. Researchers now describe 16 patients with this condition who were referred to a Boston diabetic neuropathy clinic.

Each patient developed severe neuropathic pain within 8 weeks of initiating intensive glycemic control. Nine patients (age range, 19–29) had type 1 diabetes, and 7 patients (age range, 31–58) had type 2 diabetes. Other common causes of neuropathy were ruled out. Average glycosylated hemoglobin levels were about 14% before intensive glycemic control and about 7% afterward. Pain was in a stocking-glove distribution in 13 patients and was diffuse in 3 patients. Autonomic symptoms (e.g., orthostatic hypotension, gastrointestinal dysfunction) occurred commonly, and standardized tests of sympathetic and parasympathetic function were abnormal in most patients. Retinopathy also worsened during the first 6 months of sustained glycemic control. Pain subsided eventually in most patients, but only after 1 to 2 years of combination drug therapies for neuropathic pain.

Comment:

In this case series — the largest to date — researchers make a convincing case for the existence of what they call "treatment-induced diabetic neuropathy." I have seen several such patients, but until now I was unaware of this syndrome. The pathophysiology and incidence of this clinical entity are unclear. However, the parallel worsening of neuropathy and retinopathy suggests a common mechanism, and, interestingly, transient worsening of retinopathy during the first year of intensive insulin therapy has occurred previously in clinical trials.

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Allan S. Brett, MD
Published in Journal Watch General Medicine May 20, 2010

Citation(s): Gibbons CH and Freeman R. Treatment-induced diabetic neuropathy: A reversible painful autonomic neuropathy. Ann Neurol 2010 Apr; 67:534.