Treatment-induced neuropathy of diabetes (TIND)

Background

• rare, iatrogenic small fiber neuropathy
• due to abrupt improvement in glycemic control in the setting of chronic hyperglycemia/untreated DM
• high prevalance in tertiary DM clinics (about 10%)
• risk is associated with the rate and magnitude of change in A1C
• risk increased with T1DM and Hx of eating disorders
• occurs with both insulin and oral antihyperglycemics

Presentation

• no specific cutoffs, but about >2% A1C improvement over 3 months
• new onset neuropathic pain and/or autonomic dysfunction:
  • allodynia, hyperalgesia
  • paraesthesias
  • erectile dysfunction
  • orthostatic intolerance
  • (pre) syncope
  • postprandial fullness
  • anorexia, early satiety
  • hyper/anhidrosis
• progression in retinopathy
• progression in microalbuminuria

Management

• "permissive hyperglycemia" has been proposed but evidence for/against is lacking
• typically initially refractory to treatment, particularly pain, but will improve over time (months)
• symptomatic treatment can consist of:
  • prokinetic agents such as erythromycin/domperidone for gastroparesis
  • ivabradine or other negative chronotropes for tachycardia
  • fludrocortisone for postural hypotension
  • pregabalin for neuropathic pain

References

1. Treatment-induced neuropathy of diabetes: an acute, iatrogenic complication of diabetes | Brain | Oxford Academic (oup.com)
2. Insulin neuritis and diabetic cachectic neuropathy: a review - PubMed (nih.gov)
3. ‘Insulin neuritis’ to ‘treatment-induced neuropathy of diabetes’: new name, same mystery | Practical Neurology (bmj.com)