Treatment Induced Diabetic Neuropathy

Treatment Induced Neuropathy in Diabetes (TIND) also known as Insulin Neuritis is an acute form of neuropathy that can occur with rapid reduction of HbA1c (>2-3% in <3 months) in people who have a long history of poor control (HbA1c>9%). It presents with pain and burning of peripheral limbs and can be associated with allodynia, pain from stimuli that doesn’t normally invoke pain (i.e. bedsheets resting on feet at night), and hyperalgesia, increased pain from a stimulus that would normally invoke pain. PWD suffering from TIND may also develop orthostatic hypotension (rapid drop in BP from sitting to standing position), worsening retinopathy, or worsening nephropathy. Physiologic mechanisms of TIND are unclear, but it is thought to be due to vitamin deficiencies, inflammation, hemodynamic changes (like those in retinopathy), cell death as a result of ischemia, and/or nerve regeneration leading to abnormal nerve firing. Though less responsive to pharmacological pain management, symptoms of TIND are often reversible. More studies are required to analyze the long-term effect and prevention of TIND. The overall HbA1c goals recommended by the ADA, AACE, etc. are not in question, but should there be a standard for rate of change in HbA1c reduction among clinicians? We already know the significant impact of prolonged elevated HbA1c (as demonstrated in the DCCT trial), so what do you all think about delaying HbA1c reduction to help potentially avoid TIND? Do the rewards outweigh the benefits? LMK your thoughts!