Describe the diabetic autonomic neuropathy.
Diabetic autonomic neuropathy is a type of diabetic neuropathy characterized by damage to small fiber autonomic nerves; multiple organ systems are susceptible.
List genitourinary symptoms.
Sexual dysfunction (e.g., erectile dysfunction)
Neurogenic bladder, e.g.:
Urinary retention
Incomplete bladder emptying
Bladder distention
Overflow incontinence
Poor urinary stream
List cardiovascular symptom.s
Early: decreased heart variability [6]
Late:
Orthostatic hypotension
Tachycardia at rest
Patients with cardiovascular autonomic neuropathy are at increased risk for silent myocardial infarction, arrhythmias, and death. [5][6]
List GI symptoms.
Diabetic gastroparesis
Stool changes (e.g., diarrhea, fecal incontinence, constipation)
Esophageal dysmotility
List other neuropathies symptoms.
Impaired pupillary tone [10]
Sudomotor dysfuncton
Dry skin
Heat intolerance
Abnormal sweating (e.g., anhidrosis, gustatory sweating)
Hypoglycemia unawareness
Describe diagnostics.
Perform a focused history based on the suspected affected organ.
Obtain diagnostic studies as needed to rule out alternative etiologies and confirm the diagnosis.
Describe the management.
Optimize diabetes management to achieve glycemic targets in DM.
Treat dyslipidemia and hypertension, if present.
If possible, discontinue medications that may contribute to symptoms.
Consider specialist referral.
Treatment varies depending on the organ system(s) affected:
Genitourinary symptoms: See “Treatment of urinary incontinence” and “Sexual dysfunction.”
Symptoms of diabetic gastroparesis, see “Management of diabetic gastroparesis.”
Manage orthostatic hypotension.
Nonpharmacological management of orthostatic hypotension and syncope, including regular exercise
Pharmacological management (e.g., fludrocortisone, midodrine)
Describe the prevention.
Educate patients on symptoms of diabetic neuropathies.
Encourage smoking cessation.
Initiate ASCVD prevention.
Perform annually, starting at the time of diagnosis for patients with T2DM and 5 years after diagnosis for patients with T1DM (earlier if symptoms develop).
Screening for diabetic peripheral neuropathy
Inquire about subjective symptoms of diabetic peripheral neuropathy.
Assess ankle reflexes and perform a focused examination of sensation.
Screening for diabetic autonomic neuropathy
Inquire if patient is experiencing:
Symptoms of diabetic gastroparesis
Symptoms of erectile dysfunction or female sexual dysfunction
Recurrent urinary tract infections and/or symptoms of urinary incontinence
Peripheral dry and/or cracked skin
Symptoms of hypotension or syncope
Record resting heart rate: A resting heart rate > 100 bpm suggests cardiovascular autonomic neuropathy.
Check orthostatic vital signs.
Assess for decreased heart rate variability by recording an ECG either:
When the patient rises from seated to standing
Continuously while the patient takes deep breaths for 1–2 minutes
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