Edit concept Question Editor Create issue ticket

Diabetic Autonomic Neuropathy

Autonomic Neuropathy Diabetes

Diabetic autonomic neuropathy is one of the commonest complications of diabetes. Although it can involve the autonomic nervous system diffusely, symptoms are confined to a single organ system and are responsible for increased incidence of morbidity, reduced quality of life and mortality.


Presentation

Diabetic neuropathy affects the peripheral sensory and motor nerves as well as the autonomic nervous system while diabetic autonomic neuropathy (DAN) involves all organ systems [1] but manifests initially in the longer nerves such as the vagus nerve. Although DAN is known to occur at any time in patients with type 1 and type 2 diabetes, it typically develops in patients with long-standing diabetes with poor blood glucose control. Subclinical DAN, however, can appear within a year of detecting type 2 diabetes and up to 2 years after the diagnosis of type 1 diabetes [2]. The prevalence of DAN varies amongst published studies [3] depending upon the measures used to assess the condition.

The overt clinical manifestations due to autonomic dysfunction and microvascular complications can occur concurrently but without a specific pattern [4] and can be classified according to the involved organ system as follows:

Hypothermia
  • Changes in the body's ability to regulate temperature may make you more prone to body chilling (hypothermia) or heat-related illness, such as heatstroke or heat exhaustion.[wa.kaiserpermanente.org]
Hypoxemia
  • […] variability and circadian rhythm of heart rate and blood pressure, painless myocardial ischemia/infarction, orthostatic hypotension, exercise intolerance, perioperative instability, sudden death; 2) respiratory system: reduced ventilatory drive to hypercapnia/hypoxemia[ncbi.nlm.nih.gov]
Constipation
  • Add fluid and fiber to your diet to prevent bloating and constipation . Laxatives can help with constipation, and other medicines can treat diarrhea and belly pain . Sleep with the head of your bed raised to prevent heartburn .[webmd.com]
  • Add fluid and fiber to your diet to prevent bloating and constipation. Laxatives can help with constipation, and other medicines can treat diarrhea and belly pain. Sleep with the head of your bed raised to prevent heartburn.[webmd.com]
  • Autonomic neuropathy was assessed by the presence of symptoms like dysphagia, abdominal fullness, nausea, vomiting, diarrhea /- nocturnal, faecal incontinence or constipation, dysuria, urinary incontinence, the gustatory sweating, impotence etc. and were[ncbi.nlm.nih.gov]
  • Constipation is the most common lower-GI symptom but can alternate with episodes of diarrhea. Diagnostic approaches should rule out autonomic dysfunction and the well-known causes such as neoplasia.[ncbi.nlm.nih.gov]
Diarrhea
  • Her diarrhea had previously been successfully managed with three daily injections of octreotide without adverse consequences.[ncbi.nlm.nih.gov]
  • […] the hypotension and diarrhea and led to better blood glucose control.[ncbi.nlm.nih.gov]
  • First-line treatments include midodrine for orthostatic hypotension, prokinetic drugs for gastroparesis, broad-spectrum antibiotics for diabetic diarrhea, and sildenafil for erectile dysfunction.[ncbi.nlm.nih.gov]
  • Diarrhea can occur when the nerves that control the small intestine are damaged. The diarrhea occurs most often at night. Constipation is another common result of damage to nerves in the intestines. Sometimes, the stomach is affected.[diabetes.org]
  • Autonomic neuropathy was assessed by the presence of symptoms like dysphagia, abdominal fullness, nausea, vomiting, diarrhea /- nocturnal, faecal incontinence or constipation, dysuria, urinary incontinence, the gustatory sweating, impotence etc. and were[ncbi.nlm.nih.gov]
Nausea
  • Autonomic neuropathy was assessed by the presence of symptoms like dysphagia, abdominal fullness, nausea, vomiting, diarrhea /- nocturnal, faecal incontinence or constipation, dysuria, urinary incontinence, the gustatory sweating, impotence etc. and were[ncbi.nlm.nih.gov]
  • Insular source location was associated with HRV assessments (all P 0.02), and the shift (expressed in mm) correlated negatively with physical health (P 0.001) and positively with nausea (P 0.03) and postprandial fullness (P 0.03).[ncbi.nlm.nih.gov]
  • This can result in symptoms such as abdominal bloating, nausea, heartburn and unpredictable changes in blood glucose levels. Read more on the symptoms and treatment of gastroparesis .[diabetes.co.uk]
  • This can result in symptoms such as abdominal bloating, nausea, heartburn and unpredictable changes in blood glucose levels. Read more on the symptoms and treatment of gastroparesis.[diabetes.co.uk]
  • This may cause frequent bloating, belching, heartburn, nausea, or vomiting. Diarrhea, because of abnormally fast passage of waste through the intestines. Diarrhea is more common at night. Belly pain.[wa.kaiserpermanente.org]
Vomiting
  • Autonomic neuropathy was assessed by the presence of symptoms like dysphagia, abdominal fullness, nausea, vomiting, diarrhea /- nocturnal, faecal incontinence or constipation, dysuria, urinary incontinence, the gustatory sweating, impotence etc. and were[ncbi.nlm.nih.gov]
  • It loses the ability to move food through the digestive system, causing vomiting and bloating. This condition, called gastroparesis , can change how fast the body absorbs food. It can make it hard to match insulin doses to food portions.[diabetes.org]
  • […] syncope, dizziness, tachycardia at rest, poor tolerance to exercise, orthostatic hypotension, asymptomatic myocardial ischemia Gastrointestinal (GI) symptoms are common and include esophageal dysfunction, dysphagia, gastroparesis with bloating, nausea, vomiting[symptoma.com]
  • Symptoms are wide-ranging, the ADA says, and can include: • Indigestion or heartburn • Nausea, vomiting undigested food or bloating • Diarrhea or constipation • Blood glucose levels are suddenly difficult to predict • Bladder control problems • Frequent[diabeteshealth.com]
  • This may cause frequent bloating, belching, heartburn, nausea, or vomiting. Diarrhea, because of abnormally fast passage of waste through the intestines. Diarrhea is more common at night. Belly pain.[wa.kaiserpermanente.org]
Fecal Incontinence
  • ., esophageal enteropathy, gastroparesis, constipation, diarrhea, and fecal incontinence) are common, and any section of the GI tract may be affected. Gastroparesis should be suspected in individuals with erratic glucose control.[ncbi.nlm.nih.gov]
  • incontinence Female Sexual Dysfunction : Decreased sexual desire, Increased pain during intercourse, Decreased sexual arousal, Inadequate lubrication Abnormal blood pressure regulation : Non-dipping, Reverse dipping Constipation Orthostatic Hypotension[diapedia.org]
  • Diabetic diarrhea occurs usually at night, is watery and painless, and can be associated with fecal incontinence. Bouts of diarrhea can be episodic, along with intermittently normal bowel habits or even alternating with periods of constipation.[diabetesforecast.org]
Hypotension
  • Patients with postural hypotension have intermittent symptoms over the years but rarely become severely disabled. They have a poorer prognosis than patients with symptomatic autonomic neuropathy without postural hypotension.[ncbi.nlm.nih.gov]
  • CONCLUSION: Ergotamine may be considered in refractory cases of postural hypotension.[ncbi.nlm.nih.gov]
  • […] the hypotension and diarrhea and led to better blood glucose control.[ncbi.nlm.nih.gov]
  • […] the aetiology of diabetic autonomic postural hypotension than previously thought.[ncbi.nlm.nih.gov]
  • First-line treatments include midodrine for orthostatic hypotension, prokinetic drugs for gastroparesis, broad-spectrum antibiotics for diabetic diarrhea, and sildenafil for erectile dysfunction.[ncbi.nlm.nih.gov]
Orthostatic Hypotension
  • First-line treatments include midodrine for orthostatic hypotension, prokinetic drugs for gastroparesis, broad-spectrum antibiotics for diabetic diarrhea, and sildenafil for erectile dysfunction.[ncbi.nlm.nih.gov]
  • The proposed causes of orthostatic hypotension include damaged sympathetic vasoconstrictor fibres, and impaired baroreceptor function. 1 Few papers have described the treatment of diabetic orthostatic hypotension with β -blockers. 2 Combined β 1 and β[nature.com]
  • People with orthostatic hypotension are advised to avoid sitting up or standing up suddenly; wear compression stockings; avoid medications that aggravate orthostatic hypotension, such as tricyclic antidepressants; eat small, frequent meals; and drink[diabetesselfmanagement.com]
  • KEYWORDS: Autonomic; cardiac autonomic neuropathy; diabetic neuropathy; hypoglycemia-associated autonomic failure; orthostatic hypotension; parasympathetic; sympathetic; treatment-induced neuropathy[ncbi.nlm.nih.gov]
  • Orthostatic hypotension with a decrease in systolic blood pressure of more than 30 mm Hg on standing up is noted in DAN.[symptoma.com]
Tachycardia
  • Cardiac autonomic neuropathy (CAN) has been linked to resting tachycardia, postural hypotension, orthostatic bradycardia and orthostatic tachycardia (POTTS), exercise intolerance, decreased hypoxia-induced respiratory drive, loss of baroreceptor sensitivity[ncbi.nlm.nih.gov]
  • Physical examination is likely to indicate variability in heart rate (resting tachycardia followed by bradycardia and later a fixed heart rate).[symptoma.com]
  • The manifestations of DAN cause multiple symptoms and involve the 1) cardiovascular system: resting tachycardia, reduced heart rate variability and circadian rhythm of heart rate and blood pressure, painless myocardial ischemia/infarction, orthostatic[ncbi.nlm.nih.gov]
  • The clinical signs and symptoms of CAN include tachycardia (abnormally rapid heartbeat) during rest, exercise intolerance (blunted cardiac output in response to activity), and orthostatic hypotension (a drop in blood pressure upon standing).[diabetesselfmanagement.com]
  • Symptoms and Signs Resting tachycardia due to parasympathetic damage is one of the most typical signs of CAN.[touchendocrinology.com]
Decreased Sweating
  • Decreased sweating may be evident on examination. For example, on a very warm day if the socks are very dry this likely represents decreased sweating. 4.[americanautonomicsociety.org]
  • If you experience excessive sweating, your doctor may prescribe a medication that decreases sweating, such as glycopyrrolate (Ribinul, Robinul Forte) or clonidine (Catapres).[diabetesdaily.com]
  • sweating in the feet or increased sweating in the hands, nausea or bloating after eating, persistent diarrhea or constipation, or leaking of urine.[clinicaltrials.gov]
  • sweating Exercise intolerance Paresthesias: numbness or tingling in feet, legs, hands, arms or other body parts Cleveland Clinic News & More Cleveland Clinic News & More[my.clevelandclinic.org]
Increased Sweating
  • sweating in the hands, nausea or bloating after eating, persistent diarrhea or constipation, or leaking of urine.[clinicaltrials.gov]
Urinary Retention
  • Gastrointestinal Urogenital Impaired Rate Variability Gastroparesis : Nausea, Bloating, Loss of appetite, Early satiety, Postprandial vomiting Bladder dysfunction : Frequency, Urgency, Nocturia, Hesitancy, Weak stream, Dribbling, Urinary incontinence, Urinary[diapedia.org]
  • Signs and symptoms [ edit ] The signs and symptoms of autonomic neuropathy include the following: [ citation needed ] Urinary bladder conditions: bladder incontinence or urinary retention Gastrointestinal tract : dysphagia , abdominal pain , nausea ,[en.wikipedia.org]
  • retention) but unlike peripheral autonomic neuropathies have extrapyramidal dysfunction (akinesia, tremor, rigidity).[patient.info]
Overflow Incontinence
  • These conditions can progress to overflow incontinence and urinary tract infections. Hyperglycemia alone also can cause increased urine production and incontinence.[aafp.org]
Peripheral Neuropathy
  • The patients were also tested for glycemic control and presence of peripheral neuropathy.[ncbi.nlm.nih.gov]
  • These results suggest that the PSA of heart rate variations and the measurement of VPT are useful tools for evaluating diabetic autonomic and peripheral neuropathies.[ncbi.nlm.nih.gov]
  • OBJECTIVE: To determine if hyperhomocysteinemia is a risk factor for the development of diabetic sensorimotor peripheral neuropathy (DSPN) and diabetic autonomic neuropathy (DAN).[ncbi.nlm.nih.gov]
  • These autonomic manifestations of diabetes are responsible for the most troublesome and disabling features of diabetic peripheral neuropathy and result in a significant proportion of the mortality and morbidity associated with the disease.[ncbi.nlm.nih.gov]
  • We tested whether LRP demonstrates autonomic pupillary dysfunction in diabetics independently from cardiac autonomic neuropathy (CAN) or peripheral neuropathy (PN).[ncbi.nlm.nih.gov]
Dysautonomia
  • Pathophysiology Cardiovascular autonomic neuropathy (CAN) is the most frequent complication of diabetes and one of the major components of diabetic dysautonomia.[touchendocrinology.com]
  • Dysautonomia Foundation, Inc. FD Now Faces and Voices of FD - an educational video on FD from the Dysautonomia Foundation, Inc.[dysautonomiainternational.org]
  • Signs and causes of autonomic neuropathy The primary cause of autonomic neuropathy is diabetes, but there are other causes as well, including: Familial dysautonomia Idiopathic orthostatic hypotension Multiple system atrophy with autonomic failure Parkinson[belmarrahealth.com]
  • Autonomic neuropathy is also called autonomic dysfunction or dysautonomia. These terms describe many conditions that cause the autonomic nervous system (ANS) not to work.[my.clevelandclinic.org]

Workup

The diagnosis of DAN focuses on symptoms linked to a specific organ system. The patient history will elicit symptoms of DAN, review history of diabetes management, family history of diabetes, medication history and exclude other etiologies of neuropathy like alcoholism, vitamin B12 deficiency, malignancy and autoimmune diseases. Physical examination is likely to indicate variability in heart rate (resting tachycardia followed by bradycardia and later a fixed heart rate). Examination of the skin may reveal areas of alopecia with changes in the skin and nails and callus formation. There may also be erythematous "peritrophic" intertriginous areas between the toes. Neurological examination is essential to evaluate the ability for mental arithmetics which can be diminished in DAN. An ophthalmic evaluation is also required to detect effects of DAN on the eyes.

Laboratory tests include complete blood count, fasting and post-meal blood glucose levels, hemoglobin A1c levels as well as lipid profile, serum blood urea nitrogen and serum creatinine (to exclude concomitant diabetic nephropathy). Serial blood glucose testing may be required to monitor DAN.

Since the cardiovascular system is most commonly affected with life-threatening problems and as several tests are available to evaluate it, DAN is tested first. Five noninvasive tests for DAN include the Valsalva maneuver, the response of heart rate to deep breathing and standing; and blood pressure response to standing and sustained handgrip [5]. Orthostatic hypotension with a decrease in systolic blood pressure of more than 30 mm Hg on standing up is noted in DAN. An electrocardiogram (ECG) may show prolonged corrected QT interval and QT dispersion indicating an imbalance between the sympathetic innervation on the two sides of the heart [6]. Power spectral analysis of short R-R intervals or a 24 hour ECG is a sensitive and early test for identification of DAN [7] [8]. Exercise stress test is likely to reveal limited or decreased tolerance while echocardiography may show decreased cardiac ejection fraction with systolic dysfunction and poor diastolic filling [9].

Gastric scintigraphy can be employed to evaluate gastric emptying although its results do not correlate with the symptom severity in DAN patients. Other imaging tests are usually not helpful in the diagnosis of DAN.

Suppression
  • Restoration of dopaminergic tone suppresses the sympathetic dominance and reduces cardiovascular events and mortality by close to 50%. Cinderella's slipper can now be worn! 2013 Elsevier B.V. All rights reserved.[ncbi.nlm.nih.gov]
  • Neuropathies due to an autoimmune reaction are sometimes treated with drugs that suppress the immune system (immunosuppressants) and lessen the reaction, such as azathioprine, cyclophosphamide, or prednisone.[merckmanuals.com]

Treatment

  • Treatment is based on four cornerstones: 1) causal treatment aimed at near-normoglycemia; 2) treatment based on pathogenetic mechanisms; 3) symptomatic treatment; and 4) avoidance of risk factors and complications.[ncbi.nlm.nih.gov]
  • Treatment of DAN is complex in the older adult because of poor tolerability of many pharmacologic treatment options; therefore, great care must be taken when selecting therapy as to avoid unwanted adverse effects.[ncbi.nlm.nih.gov]
  • Abstract Recent studies have suggested a role for neurotrophic substances in the pathogenesis and treatment of diabetic neuropathy.[ncbi.nlm.nih.gov]
  • Insulin treatment was started. He developed severe symptomatic postural hypotension. This resolved six months later by which time he had regained his normal weight.[ncbi.nlm.nih.gov]
  • Treatment for symptomatic postural hypotension includes avoidance of dehydration, adequate salt intake, and fludrocortisone. Other treatments are reviewed but are less helpful.[ncbi.nlm.nih.gov]

Prognosis

  • They have a poorer prognosis than patients with symptomatic autonomic neuropathy without postural hypotension.[ncbi.nlm.nih.gov]
  • Abstract Diabetic autonomic neuropathy (DAN) is associated with a markedly reduced quality of life and poor prognosis.[ncbi.nlm.nih.gov]
  • Abstract Diabetic autonomic neuropathy (DAN) represents a major complication of diabetes mellitus but there is considerable uncertainty about its incidence, prevalence, pathogenesis, diagnosis, and prognosis.[ncbi.nlm.nih.gov]
  • Symptoms of autonomic neuropathy, particularly postural hypotension, gastric symptoms and hypoglycaemic unawareness, together with abnormal autonomic function tests, carry a very poor prognosis.[academic.oup.com]
  • These results suggest that traditional cardiovascular risk factors are important correlates of DAN and may relate to both its cause and poor prognosis.[jamanetwork.com]

Etiology

  • BACKGROUND: Previous studies have suggested that IDDM subjects with diabetic autonomic neuropathy (DAN) have a greatly increased risk of mortality which may relate to a specific cardiologic etiology.[ncbi.nlm.nih.gov]
  • The patient history will elicit symptoms of DAN, review history of diabetes management, family history of diabetes, medication history and exclude other etiologies of neuropathy like alcoholism, vitamin B12 deficiency, malignancy and autoimmune diseases[symptoma.com]
  • However, the independent association of CAN with diabetic cardiomyopathy has not been established because of related etiologies for both conditions.[imaging.onlinejacc.org]
  • It demonstrates that tissue hypoxia was the etiology in this problem wound, not diminished blood flow. Final Notes Dysfunction from autonomic neuropathy can be a complicating factor in the diabetic population.[podiatrytoday.com]

Epidemiology

  • OBJECTIVE: To review the epidemiology, pathophysiology, screening and diagnosis, and optimal treatment of diabetic autonomic neuropathy (DAN) and its implications in older adults.[ncbi.nlm.nih.gov]
  • This article reviews recent developments in knowledge of epidemiology, pathogenesis, clinical symptoms, diagnosis, and therapy of DAN.[ncbi.nlm.nih.gov]
  • STUDY POPULATION: The Epidemiology of Diabetes Complications Study based on an incident cohort of childhood onset IDDM subjects. Data from two examinations, separated by 2 years, are utilized.[ncbi.nlm.nih.gov]
  • Indeed, in a French epidemiological study including 396 patients (245 with type 1 and 151 with type 2 diabetes) CAN was associated with obesity independent of age and diabetes duration. 6 The role of obesity is supported by the high prevalence of cardiac[touchendocrinology.com]
  • Evaluations done after additional 13-14 years of follow-up of the DCCT participants enrolled in the observational Epidemiology of Diabetes Interventions and Complications (EDIC) study, found CAN prevalence rates as high as 35% in the prior conventionally[diapedia.org]
Sex distribution
Age distribution

Pathophysiology

  • These uncovered further resources for risk stratification, pathophysiology, diagnosis, and treatment of DAN.[ncbi.nlm.nih.gov]
  • Abstract The pathophysiological mechanisms responsible for increased cardiovascular mortality in diabetic autonomic neuropathy are unknown.[ncbi.nlm.nih.gov]
  • The pathophysiology of postural hypotension is not clear, but changes in intravascular volume, heart rate, cardiac output, and splanchnic vascular resistance are similar in patients and controls.[ncbi.nlm.nih.gov]
  • Detailed information is given on the physiological (age, weight, body position, resting heart rate and blood pressure, respiratory pattern, exercise, meals, acute blood glucose changes) and pathophysiological confounding factors, with emphasis on the[ncbi.nlm.nih.gov]
  • Pathophysiology As for peripheral neuropathy, both metabolic and vascular mechanisms are probably involved in the pathogenesis of diabetic CAN.[touchendocrinology.com]

Prevention

  • These questions are increasingly important clinically because the Diabetes Control and Complications Trial has confirmed that the prevalence of severe hypoglycemia remains a major obstacle to attempts to prevent diabetic complications with intensive insulin[ncbi.nlm.nih.gov]
  • Tight glycaemic control is the cornerstone of the prevention, progression and retardation of DAN. An effective broad-spectrum pathogenetic treatment of neural deterioration remains to be established.[ncbi.nlm.nih.gov]
  • There is a particularly strong incentive to prevent IGT and related complications from advancing to DM2.[clinicaltrials.gov]
  • Intensive blood glucose control has been shown to help prevent CAN in people with Type 1 diabetes and may help people with Type 2 diabetes as well.[diabetesselfmanagement.com]
  • Add fluid and fiber to your diet to prevent bloating and constipation . Laxatives can help with constipation, and other medicines can treat diarrhea and belly pain . Sleep with the head of your bed raised to prevent heartburn .[webmd.com]

References

Article

  1. Vinik AI, Erbas T, Pfeifer MA, Feldman EL, Stevens MJ, Russell JW. Diabetic autonomic neuropathy. In: Porte D, Sherwin RS, Baron A, eds. Ellenberg & Rifkin's Diabetes Mellitus. 6th ed. New York: McGraw Hill. 2003;789-804
  2. Pfeifer MA, Weinberg CR, Cook DL, et al. Autonomic neural dysfunction in recently diagnosed diabetic subjects. Diabetes Care 1984;7:447-453
  3. Vinik AI, Maser RE, Mitchell BD, Freeman R. Diabetic autonomic neuropathy. Diabetes Care. 2003;26:1553–79.
  4. Ewing DJ. Cardiac autonomic neuropathy. In Diabetes and Heart Disease. Jarret RJ, Ed. Elsevier, Amsterdam, the Netherlands. 1984; 99–132
  5. Ewing DJ, Martyn CN, Young RJ, Clarke BF. The value of cardiovascular autonomic function tests: 10 years experience in diabetes. Diabetes Care 1985;8:491-498
  6. Ewing DJ, Boland O, Neilson JM, Cho CG, Clarke BF. Autonomic neuropathy, QT interval lengthening, and unexpected deaths in male diabetic patients. Diabetologia 1991; 34:182-185
  7. Freeman R, Saul P, Roberts M, Berger RD, Broadbridge C, Cohen R. Spectral analysis of heart rate in diabetic autonomic neuropathy. Arch Neurol 1991;48:185-190
  8. Risk M, Bril V, Broadbridge C, Cohen A. Heart rate variability measurement in diabetic neuropathy: review of methods. Diabetes Technol Ther 2001;3:63-76
  9. Kahn J, Zola B, Juni J, Vinik AI. Decreased exercise heart rate in diabetic subjects with cardiac autonomic neuropathy. Diabetes Care 1986;9:389-394

Ask Question

5000 Characters left Format the text using: # Heading, **bold**, _italic_. HTML code is not allowed.
By publishing this question you agree to the TOS and Privacy policy.
• Use a precise title for your question.
• Ask a specific question and provide age, sex, symptoms, type and duration of treatment.
• Respect your own and other people's privacy, never post full names or contact information.
• Inappropriate questions will be deleted.
• In urgent cases contact a physician, visit a hospital or call an emergency service!
Last updated: 2018-06-21 19:48