Euglycemic progression: Worsening of diabetic retinopathy in poorly controlled type 2 diabetes in minorities

Abstract

Aims In type 2 diabetes, early effects of strict near-normalization of glucose control on macrovascular and microvascular disease are still uncertain. We evaluated the effects of early dramatic improvement in glycemia on retinal disease in poorly controlled diabetes. Methods A retrospective, case-control study in public hospital patients with type 2 diabetes, who had annual retinal imaging as part of a case management program or standard diabetes care. Patients included had ≥2 two retinal images ≥1 one year apart, and at least 3 HbA1C measurements. Retinal images were graded using a modified Scottish Diabetic Retinopathy grading scheme. An ‘intensive’ group (n=34) with HbA1C decrease >1.5% was compared with randomly chosen patients (n=34) with minimal HbA1C changes. Results Mean HbA1C (±SEM) over two years was similar in intensive (8.5±0.21%) and control groups (8.1±0.28%, p=NS). However, the intensive group had higher baseline HbA1C and a mean maximal decrease of 4.0±0.41% in contrast to the control group (0.2±0.11%). Retinopathy grade progressed +0.7±0.25 units from baseline in the intensive group (p = 0.015), a 22.6% worsening. The control group changed minimally from baseline (0.03±0.14 units, p=NS). Change in retinopathy grade was significantly different between groups (p=0.02). More eyes worsened by ≥1 retinal grade (p=0.0025) and developed sight-threatening retinopathy (p=0.003) in the intensive group. Visual acuity was unchanged. Conclusions Diabetic retinopathy significantly worsened in poorly controlled type 2 diabetes after early intensification of glycemic control and dramatic HbA1C change. Retinal status should be part of risk-factor evaluation in patients likely to experience marked reductions in HbA1C in poorly controlled diabetes.

Endothelial Function in Pre-diabetes, Diabetes and Diabetic Cardiomyopathy: A Review

“…This meant that tight glycemic control might positively influence microangiopathy development. Such conclusions are in contrast with those coming from Shurter et al [45] who observed a progressive worsening of diabetic retinopathy in case-control study involving type 2 diabetes. In particular, the authors observed that a tight glycemic control improve the progression of retinopathy from baseline (+0.7+0.25 units, p=0.015), while the standard glycemic control group did not showed any significant change in the progression of their eye disease as compared to baseline (0.03 + 0.14 units, p = NS) [45].…”

“…Such conclusions are in contrast with those coming from Shurter et al [45] who observed a progressive worsening of diabetic retinopathy in case-control study involving type 2 diabetes. In particular, the authors observed that a tight glycemic control improve the progression of retinopathy from baseline (+0.7+0.25 units, p=0.015), while the standard glycemic control group did not showed any significant change in the progression of their eye disease as compared to baseline (0.03 + 0.14 units, p = NS) [45]. Chilelli et al [46] proposed a "glycoxidationcentric" theory: rather than glycemic control, AGEs control is the best way to reduce the burden of microangiopathy in diabetic patients.…”

Worsening of diabetic retinopathy with rapid improvement in systemic glucose control: A review

“…Early worsening was also demonstrated in a retrospective case‐control study in 68 public hospital patients with type 2 diabetes, predominantly from ethnic minorities (Latino/other). These patients underwent annual retinal imaging either as part of a case management programme or as standard diabetes care . An “intensive” group of patients (n = 34) with an HbA1c decrease of more than 1.5% was compared with randomly chosen (control) patients (n = 34) with minimal HbA1c changes over 2 years.…”

Progression of diabetic retinopathy after bariatric surgery

“…Results of prospective case-control studies and randomized controlled clinical trials have shown that bariatric surgery results in remission of Type 2 diabetes in~80% of cases [1]. However, there is concern that rapid lowering of glycaemia may cause a paradoxical worsening in diabetic retinopathy [3,4], as observed during intensive management in pregnancy [5,6], insulin pump therapy [7], GLP-1 analogues [8,9] and after pancreatic transplantation [10,11]. It is well known that lowering glycaemia can slow the development and progression of diabetic retinopathy in the long term [2].…”