Acute worsening of microvascular complications of diabetes mellitus during rapid glycemic control: The pathobiology and therapeutic implications

Abstract

While chronic hyperglycaemia resulting from poorly controlled diabetes mellitus (DM) is a well-known precursor to complications such as diabetic retinopathy, neuropathy (including autonomic neuropathy), and nephropathy, a paradoxical intensification of these complications can rarely occur with aggressive glycemic management resulting in a rapid reduction of glycated haemoglobin. Although, acute onset or worsening of retinopathy and treatment induced neuropathy of diabetes are more common among these complications, rarely other problems such as albuminuria, diabetic kidney disease, Charcot’s neuroarthropathy, gastroparesis, and urinary bladder dysfunction are also encountered. The World Journal of Diabetes recently published a rare case of all these complications, occurring in a young type 1 diabetic female intensely managed during pregnancy, as a case report by Huret et al. It is essential to have a comprehensive understanding of the pathobiology, prevalence, predisposing factors, and management strategies for acute onset, or worsening of microvascular complications when rapid glycemic control is achieved, which serves to alleviate patient morbidity, enhance disease management compliance, and possibly to avoid medico-legal issues around this rare clinical problem. This editorial delves into the dynamics surrounding the acute exacerbation of microvascular complications in poorly controlled DM during rapid glycaemic control.

Keywords: Diabetes mellitus; Microvascular complications; Diabetic retinopathy; Treatment induced neuropathy of diabetes; Diabetic nephropathy; Charcot’s neuropathy

Core Tip: New onset, or acute worsening of preexisting microvascular complications of diabetes mellitus (DM), is an uncommon complication of rapid improvement of chronic hyperglycaemia from intensive management of DM. Worsening of diabetic retinopathy and treatment induced neuropathy of diabetes are the two common microvascular diseases complicating intensive DM treatment with a rapid glycated haemoglobin reduction more than 2% points within a period of 3 months, though less commonly other complications such as Charcot’s neuroarthropathy, diabetic nephropathy, gastroparesis and urinary bladder dysfunction are also encountered. This editorial discusses the case of a young female type 1 diabetic, intensively managed during pregnancy, developing all these complications, published as a case report in the World Journal of Diabetes, with an appraisal of the current evidence on this uncommon phenomenon.