DIABETES AUTONOMIC

NEUROPATHY
DR. ABHIRAM KOGANTI

Diabetic Neuropathy
Diabetic neuropathy occurs in 50% of individuals with
long-standing type 1 and type 2 DM.
It may manifest as polyneuropathy, mononeuropathy,
and/or autonomic neuropathy
Most common complication of diabetes
Underdiagnosed and Undertreated
Substantial morbidity/mortality (CAN)

Diabetic neuropathy

Distal symmetric polyneuropathy

Mononeuropathies
Autonomic neuropathy
Polyradiculopathies

Risk Factors
Glucose control
Duration of diabetes
Damage to blood vessels
Mechanical injury to nerves
Autoimmune factors
Genetic susceptibility
Lifestyle factors
Smoking
Diet

DIABETIC AUTONOMIC
NEUROPATHY (DAN)

Least recognized and understood

complications of diabetes.

Can involve the entire autonomic nervous

system (ANS)

Individuals with long-standing type 1 or 2

DM may develop signs of autonomic
dysfunction involving the cholinergic,
noradrenergic, and peptidergic (peptides
such as pancreatic polypeptide,
substance P, etc.) systems.

May be either clinically evident or

subclinical

Autonomic
neuropathy
Affects the autonomic nerves
controlling internal organs

Peripheral
Genitourinary
Gastrointestinal
Cardiovascular

Is classified as clinical or subclinical

based on the presence or absence of
symptoms

Clinical Presentation
Clinical symptoms generally do not
appear until long after the onset of
diabetes. However, subclinical
autonomic dysfunction can occur within
a year of diagnosis in type 2 diabetes
patients and within two years in type 1
diabetes patients
Pfeifer MA, Weinberg CR, Cook DL, Reenan A, Halter JB,
Ensinck JW: Autonomic neural dysfunction in recently
diagnosed diabetic subjects. Diabetes Care 7:447-453,
1984

Pathophysiology

Vinik A: Diabetic Neuropathy: Pathogenesis and Therapy. Am J Med 107

(2B):17S-26S, 1999

Differential Diagnosis

Idiopathic Orthostatic hypotension

Panhypopituitarism
Pheochromocytoma
Amyloidosis
Hypovolemia from diuretics
SE from medications
CHF
Hypoglycemia due to intensive glycemic
control.

Peripheral Autonomic
Dysfunction
Contributes to the following
symptoms/signs:
- Neuropathic arthropathy (Charcot
foot,hammer toe)
- Aching, pulsation, tightness, cramping,
dry skin,
pruritus, edema, sweating abnormalities
- Weakening of the bones in the foot
leading to fractures
- Poor wound healing

Testing

Peripheral Autonomic
Dysfunction, cont.
Treatment
Foot care: footwear selection,foot hygeine,avoid
barefoot walking,prompt consultation,elevate
feet when sitting
Eliminate aggravating drugs
Reduce edema
midodrine
diuretics
Support stockings
Screen for CVD

Genitourinary
Autonomic Neuropathy
Diabetic autonomic neuropathy may lead to genitourinary dysfunction including

Cystopathy

erectile dysfunction

female sexual dysfunction (reduced sexual desire, dyspareunia, reduced

vaginal lubrication).

Symptoms of diabetic cystopathy begin with

an inability to sense a full bladder and

a failure to void completely.

As bladder contractility worsens, bladder capacity and the postvoid residual

increase, leading to symptoms of urinary hesitancy, decreased voiding
frequency, incontinence, and recurrent urinary tract infections.
Diagnostic evaluation includes cystometry and urodynamic studies.

Genitourinary
Autonomic Neuropathy
Signs/Symptoms

Treatment

Bladder dysfunction

Voluntary urinization,Cathetrization

Retrogade ejaculation

Antihistamines

Erectile dysfunction

Type 5 phosphodiesterase inhibitors

Dyspareunia

Lubricants,estrogen creams

Gastrointestinal Autonomic
Neuropathy
Symptoms/Signs
Gastroparesis resulting in anorexia, nausea, vomiting,
and early satiety
Diabetic enteropathy resulting in nocturnal diarrhea
alternating with constipation
Esophageal dysfunction - assymptomatic
Treatment
Other causes of gastroparesis or enteropathy should
first be ruled out
Gastroparesis - Small, frequent meals,
metoclopramide, erythromycin (interacts with the
motilin receptor and may produce gastric emptying)
Enteropathy - loperamide, antibiotics, stool softeners or
dietary fiber

Cardiovascular Autonomic
Neuropathy
Symptoms/Signs
Exercise intolerance
Postural hypotension
Treatment
Discontinue aggravating drugs
Change posture (make postural changes slowly,
elevate bed)
Increase plasma volume

Cardiovascular Autonomic
Neuropathy(CAN)
Most studied and clinically important
Increased CV mortality
damage to the autonomic nerve fibers
that innervate the heart and blood
vessels, resulting in abnormalities in
heart rate control and vascular
dynamics.

Central CAN
1.Tachycardia (HR >100 bpm)
2.Decreased exercise tolerance
3.Orthostasis (>20mmHg fall in systolic BP
upon standing without compensationHR)
4.Cardiac denervation syndrome= SILENT MI
5.Paradoxic supine or nocturnal hypertension
6.Intraoperative and perioperative
cardiovascular instability
7. Left ventricular diastolic dysfunction

Peripheral CAN
1. Decreased thermoregulation
2. Decreased sweating
3. Altered blood flow
4. Impaired vasomotion
5. Edema

Testing for
CAN

CAN Treatment
Nuclear Stress test
ACE I, BB, Antioxidants (Alpha-lipoic acid)
Supportive garments for orthostatic hypotension
Discontinue aggravating drugs
Change posture (make postural changes
slowly, elevate bed)

Clonidine, fludrocortisone, midodrine, octreotide?

METABOLIC
1.Hypoglycemia unawareness: decreased
counterregulatory catecholamine
responses
1.Hypoglycemia unresponsiveness:
Reduction in glucagon and epinephrine
secretion in response to Hypoglycemia

Hypoglycemia
Avoidance of recurrent hypoglycemia
Frequent FSBG testing or CMGS
Individualized HgA1c goals

DAN Screening
ADA Guidelines 2011
At the time of diagnosis DM2
5 years after diagnosis DM1
Increase risk of exercise induce injury or adverse
event
Patients should undergo cardiac investigation before
intensifying physical activity
Special testing rarely needed, may not affect
management or outcomes

DAN Screening
ADA Guidelines 2011
Comprehensive HPI
Microvascular complications:
DPN
DAN (ED,gastroparesis, incontinence, recurrent
infections, hypogycemia unawareness)
Signs: tachycardia, orthostatic hypotension, abnormal
monofilament or VPT testing
Test HR variability
E:I ratio, valsalva maneuver, standing, EKG
If normal repeat once a year

DAN treatment
!!Prevention!!
Once stablished: Improve glycemic control
can slow progression but not reversal of
neuronal loss if advanced at time of
diagnoses.
Symptomatic treatment: can improve quality
of life of the patient.