Autonomic Dysfunction Treatment Guidelines

Non-Pharmacological Management

The American Diabetes Association recommends identifying and avoiding drugs that exacerbate autonomic symptoms, such as psychotropic drugs, diuretics, and α-adrenoreceptor antagonists, in patients with autonomic dysfunction 1, 2
The European Heart Journal suggests implementing gradual staged movements with postural change to minimize orthostatic symptoms in patients with autonomic dysfunction 1
Elevating the head of the bed (10-20°) during sleep can help prevent nocturnal polyuria and maintain better fluid distribution in patients with autonomic dysfunction 1, 3
Teaching physical counter-maneuvers, such as leg-crossing, stooping, squatting, and tensing muscles, can help manage orthostatic symptoms in patients with autonomic dysfunction 1, 3
Increasing fluid (2-3 L/day) and salt intake, if not contraindicated, can help manage orthostatic symptoms in patients with autonomic dysfunction 1, 3

The American College of Cardiology recommends midodrine, an FDA-approved selective α1-adrenergic agonist, as a first-line medication for symptomatic orthostatic hypotension 1
Fludrocortisone, a mineralocorticoid, is recommended as a first-choice medication for orthostatic hypotension, with a mechanism of action involving sodium retention, direct vessel constriction, and increased water content in vessel walls 1, 4
Erythropoietin may be considered for patients with anemia (Hb <11 g/dL) and severe autonomic neuropathy, with a mechanism of action involving increased red cell mass, central blood volume, and neurohumoral effects on vascular tone 1
Desmopressin may be useful for nocturnal polyuria and morning orthostatic hypotension in patients with autonomic dysfunction 1, 3

For resting tachycardia, cardioselective β-blockers without intrinsic sympathomimetic activity (metoprolol, nebivolol, bisoprolol) may be considered in patients with autonomic dysfunction 1, 5
Several medications, including angiotensin-converting enzyme inhibitors, angiotensin II type 1 receptor blockers, cardioselective β-blockers, digoxin, and verapamil, may improve heart rate variability in diabetic patients with autonomic dysfunction 1, 5

Intensive glycemic control and multifactorial cardiovascular risk intervention can reduce the progression of cardiovascular autonomic neuropathy (CAN) in patients with diabetes-related autonomic neuropathy 2, 6