Diabetic Male with Degenerative Cervical Myelopathy (DCM) Treated by Imeglimin (Twymeeg)

Sakamoto K, Bando H, Ogawa T, Iwatsuki N and Okada M

Published on: 2026-03-21

Abstract

This case was patient is 59-year-old male of BMI 25.2 kg/m² with type 2 diabetes (T2D). He was diagnosed as progressive vertebral deformity, malalignment, and degenerative cervical myelopathy (DCM) with multiple disc bugling at C4/5-C6/7. In 2025, he developed general malaise, and diagnosed as T2D with HbA1c 7.3%. He was advised to continue standard low carbohydrate diet (LCD) and provided imeglimin (Twymeeg). HbA1c decreased to 6.0% in 4 months with remarkable clinical effect. He tolerated imeglimin well with no gastro-intestinal adverse effects (GI-AE). Certain relationship among T2D, DCM, LCD, imeglimin and others would be discussed with some perspectives.

Keywords

Degenerative cervical myelopathy (DCM); Low carbohydrate diet (LCD); Type 2 diabetes (T2D); Pulse wave velocity (PWV); Imeglimin (Twymeeg)

Introduction

Globally, medical care for the elderly has become increasingly important in recent years. Among these, type 2 diabetes (T2D), a lifestyle-related disease, is on the rise in internal medicine clinical practice [1]. Diabetes is associated with diabetic complications such as macroangiopathy and microangiopathy, as well as comorbidities [2]. These include osteoporosis, bone lesions, and degenerative cervical myelopathy (DCM) in the field of orthopedics [3]. In fact, T2D and DCM are common among the elderly, making management of these conditions important in clinical practice. Furthermore, neuropathy in DM may affect the development of DCM.

The authors and colleagues have treated elderly patients and those with diabetes, arteriosclerosis, and chronic kidney disease (CKD), and have published a variety of reports [4,5]. From the perspective of anti-aging and lifestyle-related diseases, diet has recently become increasingly important [6,7]. A calorie-restricted diet (CRD) was once considered appropriate for sick individuals [8]. Subsequently, low carbohydrate diet (LCD) has been more clinically effective than CRD [9]. This approach and social progress have been historically promoted by Dr. Bernstein and Dr. Atkins [10,11]. They published their books, and they have developed the awareness of LCD in the western countries. Meanwhile, in Japan, a group including the authors established the Japan LCD Promotion Association (JLCDPA), which continues to promote LCD through books, papers, seminars, and other activities.

Meanwhile, orthopedic diseases increase with aging. Among them, DCM is the most common cause of non-traumatic chronic spinal cord dysfunction worldwide, resulting in debilitating disabilities that reduce quality of life (QOL) [12]. Early diagnosis of DCM is often difficult due to the wide variety of clinical manifestations [13]. PC physicians play an important role in recognizing the symptoms and signs of DCM, which can lead to referral for specialist care and imaging such as MRI.

Our clinical group has treated a wide variety of patients and published research for many years. Recently, we encountered an interesting male case of T2D and DCM. For treatment, he was on LCD and the administration of imeglimin, a recently developed antidiabetic drug, resulting in clinical improvement. This case associated with related perspectives are described in this report.

Case Presentation

History and Physicals

This case was 57-year-old male, who did not have specific past history. He has noticed slight neck pain from 2024, and then visited the orthopedic clinic. He was evaluated for his neck situation and provided some analgesics, and did not have detailed blood chemistry examination at that time. He felt some improvements in the neck pain after that. In autumn 2025, he developed general malaise and visited internal medicine department. Physical examinations showed unremarkable for vitals, consciousness, head, neck, chest, abdomen and neurological examinations. His physique in 2025 showed 170 cm in height, 72.8 kg in weight, and 25.2 kg/m²in BMI. Blood chemistry showed elevated HbA1c, suggesting the existence of T2D. As basic exams, chest X-ray was negative, and electrocardiogram (ECG) showed unremarkable with no specific ST-T changes. The obtained data in recent years were summarized in Figure 1.

Figure 1: Progress of exam and treatment by Imeglimin.

Cervical MRI

A cervical MRI was performed (Figure 2). Vertebral deformation and misalignment were observed. Intervertebral disc degeneration was also progressing, with posterior bulging of the C4/5-C6/7 discs. Posterior protrusion was observed at C6/7, and mild compression of the thecal sac was observed, but the degree of spinal cord compression was not very severe. Intramedullary signal changes were also equivocal. At C5/6, the left and right intervertebral foramina appeared slightly narrow, but there was no noticeable difference between the left and right.?From these, DCM with multiple disc bugling at C4/5-C6/7 was observed.

Figure 2: Exam of neck MRI in the sagittal plane. a: T2, b: T1, c: Stir.

T2 (long TR/TE) highlights pathology (fluid/water is bright).

T1 (short TR/TE) shows anatomy (fat is bright, fluid is dark).

STIR suppresses fat to enhance lesion detection.

Exams and Progress

Fundamental blood test showed elevated value of HbA1c 7.3%, and blood glucose 134 mg/dL, and he was diagnosed as T2D. For the treatment of T2D, we have advised him to continue LCD for petite-standard level, and started to provide imeglimin (Twymeeg) 2000mg/day (Figure 1). Consequently, HbA1c value showed 7.3%, 6.7%, 6.3% and 6.0% for 4 months, in which diabetic situation has been improved. He tolerated the administration of Twymeeg, with no symptoms of gastro-intestinal adverse effects (GI-AE) during the clinical progress.?

Ethical Standards

This case has complied with the guideline for Declaration of Helsinki. In addition, comments were presented for personal information. The principle was shown in ethical rule for clinical research. Some guidelines were on the regulation for Ministry of Education, Culture, Sports, Science Technology and also Ministry of Health, Labor and Welfare. The authors and collaborators established the ethic committee that was in Sakamoto hospital, Kagawa, Japan. The committee included some medical staffs, such as director, physician, pharmacist, nurse, nutritionist, and legal professional. The members discussed enough the protocol, and the informed consent was obtained by written document.

Discussion

This case has some characteristic aspects, in which some relationships exist among T2D, LCD, imeglimin, cervical herniation, and the results of PWV. Among them, the association would be considered between orthopedic cervical spine lesions and diabetes. T2D patients tend to have DCM, and the pain from DCM was studied. A cross-sectional investigation was reported from 86 cases with DCM [14]. They answered some questionnaires of Patient-reported outcome measures (PROMs), such as Neck Disability Index (NDI) and Core Outcome Measure Index for the neck (COMI-Neck). As a result, pain was predominantly found in the neck and lower back. From QOL point of view, symptom-specific well-being score by the COMI-Neck showed higher influences.

A research was conducted concerning the relationship of DM and DCM. The protocol was prospective multi-center cohort study, and included 875 cases of DCM, that included 200 diabetic cases [3]. They received some questionnaires such as SF-36, JOA score, JOA Cervical Myelopathy Evaluation Questionnaire and Neuropathic Pain Symptom Inventory [15]. As a result, diabetic cases showed higher age and higher BMI value than subjects without diabetes. The elevation of HbA1c showed weak relationship with less impairment of JOA score. A systematic review was conducted for the relationship between DCM and metabolic factors [16]. Out of 8523 reports, 57 met the criteria for final analysis. Among them, 91% showed the assessment of clinical influence of diabetes related to DCM. Generally, DCM cases with diabetes and/or cardiovascular disease (CVD) showed elevated perioperative morbidity associated with poorer neurological outcome. The association with DCM and diabetes in this case is interesting. The timing of the onset is unclear. Previous data from this case suggests that there was no obvious diabetes between 2021 and 2023. The exact cause of the neck pain is unknown, and it will be necessary to monitor the progress of this condition in the future.

Concerning actual practice of LCD, Japan LCD promotion association (JLCDPA) has adopted three useful types. They are super LCD, standard LCD and petite LCD, in which carbohydrate ratio includes 12%, 26%, and 40%, respectively [17]. When super LCD as strict type will be continued for months, weight reduction ratio would be more than 10% of weight in 24% of the subjects [18]. For oral hypoglycemic agent (OHA), imeglimin (Twymeeg) has been introduced to clinical practice for several years, in which beneficial efficacy has been found until now [19]. It shows specific pharmacological function through mitochondrial pathway [20]. It can increase insulin secretion from beta cell in the pancreas and decrease insulin resistance in some organs [21]. For actual treatment, imeglimin has shown constant benefit for wide range of patients with T2D so far [7,22].

Some limitation may exist for this article. This patient revealed good response of imeglimin for diabetic control. However, the relationship between diabetes and DCM has not been apparently elucidated or analyzed. Some other factors may be involved in current pathology, and then the case will be followed up with careful attention.

In summary, general clinical progress for 59-year-old case was described with related perspectives. His problems included T2D, LCD, imeglimin, DCM and others. Various factors are involved in T2D, such as diabetic complications and comorbidities. This article will hopefully become useful reference for medical practice and research in the future.

Conflict of Interest

The authors declare no conflict of interest.

Funding

There was no funding received for this paper.

International Journal of Endocrinology and Diabetes