Download Autonomic neuropathy

Autonomic neuropathy
Patients with long-standing diabetes may develop neuropathy affecting autonomic function, which may
produce a number of different clinical and management problems. Symptoms are often non-specific and
other diagnoses should be considered and excluded.

Erectile dysfunction: the advent of selective inhibitors of phosphodiesterase in erectile tissue has
revolutionised the management of this relatively common problem in diabetic men. Treatment is
successful in more than 50% of patients. Sildenafil is available on prescription for patients with
diabetes; its use should be avoided in cases of severely compromised cardiovascular function and when
nitrates are being taken. Newer agents claiming longer action are becoming available. Where oral
therapies are unsuccessful, referral can be made to a specialist ED clinic (run in Aberdeen by the
Urology Department and Mr Gunn in Elgin) for consideration of intracavernosal injection of
prostaglandin or vacuum devices.

Intermittent diarrhoea: especially occurring nocturnally, this problem may be a direct result of
gastrointestinal neuropathy in which codeine phosphate or other antidarrhoeal agents can be helpful.
Alternatively, gut dysmotility can lead to atypical bacterial overgrowth and short courses of
antimicrobial agents such as tetracycline or metronidazole can be rapidly effective. [Remember also
other possible causes of diarrhoea, including Metformin therapy, the possibility of coeliac disease or
exocrine pancreatic dysfunction in cases of secondary diabetes].

Postural hypotension: avoid rising up too quickly, and over-enthusiastic use of diuretics and
hypotensive agents. Fludrocortisone may be useful in severe cases but may lead to oedema.
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Vomiting due to gastroparesis: metoclopramide or domperidone may help by promoting gastric
emptying. Erythromycin may benefit some patients.

Gustatory sweating: fortunately uncommon; best managed by avoidance of foods found by the sufferer
to exacerbate the problem. The anticholinergic agent propantheline may be beneficial but often has
marked anticholinergic adverse effects.

Neuropathic oedema: damage to control of capillary blood flow can lead to accumulation of fluid in
dependent extremities in the presence of a normal serum albumin and the absence of fluid overload.
Ephedrine, an alpha-adrenergic agonist may be useful but care is required in the presence of
hypertension and angina.

Bladder hypotonia: drug treatment with alpha blocking agents is difficult due to the risk of
precipitating symptomatic postural hypotension.