From the Guidelines
Autonomic neuropathy is a condition characterized by damage to the nerves controlling involuntary bodily functions, such as heart rate, blood pressure, digestion, and temperature regulation, with major clinical manifestations including resting tachycardia, orthostatic hypotension, gastroparesis, and erectile dysfunction, as outlined in the 2025 standards of care in diabetes 1.
Key Characteristics of Autonomic Neuropathy
- The symptoms and signs of autonomic neuropathy should be elicited carefully during the history and physical examination, including resting tachycardia, orthostatic hypotension, gastroparesis, constipation, diarrhea, fecal incontinence, erectile dysfunction, neurogenic bladder, and sudomotor dysfunction with either increased or decreased sweating 1.
- Screening for symptoms of autonomic neuropathy includes asking about symptoms of orthostatic intolerance, syncope, exercise intolerance, constipation, diarrhea, urinary retention, urinary incontinence, or changes in sweat function 1.
- Further testing can be considered if symptoms are present and will depend on the end organ involved but might include cardiovascular autonomic testing, sweat testing, urodynamic studies, gastric emptying, or endoscopy or colonoscopy 1.
Management and Treatment
- Strict blood glucose control is essential for managing diabetic autonomic neuropathy, typically achieved through insulin therapy or oral medications 1.
- Orthostatic hypotension can be managed with medications such as fludrocortisone or midodrine, along with increased salt intake and compression stockings.
- Gastrointestinal symptoms can be managed with medications such as metoclopramide for gastroparesis and loperamide for diarrhea.
- Erectile dysfunction often responds to medications such as sildenafil.
- Lifestyle modifications are crucial, including regular physical activity, small frequent meals for digestive issues, and avoiding rapid position changes.
From the Research
Definition and Overview of Autonomic Neuropathy
- Autonomic neuropathies are a complex group of disorders that result in diverse clinical manifestations affecting the cardiovascular, gastrointestinal, urogenital, and sudomotor systems 2.
- These disorders can occur in conjunction with somatic neuropathies or in isolation, and their symptoms can be debilitating, reducing the quality of life in affected patients 3, 2.
Clinical Manifestations
- Symptoms of autonomic dysfunction can include orthostatic hypotension, supine hypertension, constipation, bladder and sexual dysfunction, syncope, bowel and bladder hypomotility, pupillary dysfunction, and dry mouth and eyes 3, 2, 4, 5, 6.
- The autonomic reflex screen is a validated tool to assess sympathetic postganglionic sudomotor, cardiovascular sympathetic noradrenergic, and cardiac parasympathetic function 2.
Diagnosis and Treatment
- Initial laboratory evaluation for autonomic neuropathies includes fasting glucose or oral glucose tolerance test, thyroid function tests, kidney function tests, vitamin-B12, serum, and urine protein electrophoresis with immunofixation 2.
- Disease-modifying therapies should be used when available in combination with non-pharmacological management and symptomatic pharmacologic therapies 2.
- Treatment should be individualized, and non-pharmacological approaches, such as lifestyle measures and physical counter maneuvers, can be effective in managing autonomic symptoms 3, 2, 6.
- Pharmacological treatment options, including midodrine, droxidopa, pyridostigmine, atomoxetine, and yohimbine, can be used to manage symptoms such as orthostatic hypotension 5, 6.