Diabetic Autonomic Neuropathy Management

Prevention and General Management

Intensive diabetes therapy significantly retards the development of cardiovascular autonomic neuropathy in type 1 diabetes, according to the American Diabetes Association (level A evidence) 3, 2
Intensive multifactorial cardiovascular risk intervention reduces the development and progression of cardiovascular autonomic neuropathy in type 2 diabetes, as recommended by the European Association for the Study of Diabetes (level B evidence) 2, 4
Lifestyle modifications, including weight reduction and physical activity, improve heart rate variability in both pre-diabetes and diabetes, as suggested by the American Heart Association (level B evidence) 2, 4
Optimizing glucose management, blood pressure, and lipid control reduces the risk or slows the progression of all forms of diabetic neuropathy, according to the American College of Cardiology 1, 5

Resting tachycardia associated with cardiovascular autonomic neuropathy can be treated with cardioselective β-blockers, such as metoprolol, nebivolol, or bisoprolol, as recommended by the European Society of Cardiology (class I recommendation) 3, 6
For orthostatic hypotension, first exclude drugs that exacerbate symptoms and correct volume depletion, as suggested by the American Autonomic Society (class I recommendation) 4, 6
Midodrine is first-line treatment for symptomatic orthostatic hypotension, according to the American Academy of Neurology (class I recommendation) 3, 4
Fludrocortisone can be used alone or in combination with midodrine for non-responders, as recommended by the European Federation of Neurological Societies (class IIa recommendation) 3, 7

Acarbose can attenuate postprandial hypotension in autonomic failure, as suggested by the American Gastroenterological Association 3, 7
Somatostatin analogues may help inhibit vasoactive gastrointestinal peptides in diabetic diarrhea, according to the European Society of Gastrointestinal Motility 3, 7

Evaluation should be performed for patients with recurrent urinary tract infections, pyelonephritis, incontinence, or palpable bladder, as recommended by the American Urological Association 1

First-line medications for painful diabetic neuropathy include pregabalin or duloxetine, as approved by the FDA 8, 1
Gabapentinoids, serotonin-norepinephrine reuptake inhibitors, tricyclic antidepressants, and sodium channel blockers can be used for neuropathic pain management, according to the American Academy of Neurology 1, 5
Opioids, including tramadol and tapentadol, should be avoided due to potential adverse events, as warned by the Centers for Disease Control and Prevention 1

Regular assessment of autonomic function is recommended in patients with diabetes, as suggested by the American Diabetes Association 5
Cardiovascular autonomic testing, including heart rate variability with deep breathing, should be performed to evaluate autonomic function, according to the European Association for the Study of Diabetes 5

Drug treatment of symptomatic orthostatic hypotension requires careful balance between increasing standing blood pressure and avoiding marked increase in supine blood pressure, as cautioned by the American Autonomic Society 3, 4
Always consider non-diabetic causes of neuropathy in patients with diabetes, as other etiologies may coexist, according to the American Academy of Neurology 5
Avoid drugs that may reduce heart rate variability in patients with cardiovascular autonomic neuropathy, as recommended by the European Society of Cardiology (class III recommendation) 3, 6