Table 4—

Treatment of autonomic neuropathy

SymptomsTestsTreatments
Cardiac
    Exercise intolerance, early fatigue and weakness with exerciseHRV, multigated angiography (MUGA) thallium scan, 123I metaiodobenzlyguanidine (MIBG) scanGraded supervised exercise, ACE inhibitors, β-blockers
    Postural hypotension, dizziness, lightheadedness, weakness, fatigue, syncopeHRV, measure blood pressure standing and supine, measure catecholaminesMechanical measures, clonidine, midodrine, octreotide
Gastrointestinal
    Gastroparesis, erratic glucose controlGastric emptying study, barium studyFrequent small meals, prokinetic agents (metoclpramide, domperidone, erythromycin)
    Abdominal pain or discomfort, early satiety, nausea, vomiting, belching, bloatingEndoscopy, manometry, electrogastrogramAntibiotics, antiemetics (phenergan, compazine, tigan, scopolamine), bulking agents, tricyclic antidepressants, pancreatic extracts, pyloric Botox, gastric pacing, enteral feeding
    ConstipationEndoscopyHigh-fiber diet and bulking agents, osmotic laxatives, lubricating agents and prokinetic agents used cautiously
    Diarrhea, often nocturnal alternating with constipation and incontinenceTrials of soluble fiber, gluten and lactose restriction, anticholinergic agents, cholestyramine, antibiotics, clonidine, somatostatin, pancreatic enzyme supplements
Sexual dysfunction
    Erectile dysfunctionHistory and physical examination, HRV, penile-brachial pressure index, nocturnal penile tumescenceSex therapy, psychological counseling, sildenafil, vardenafil, tadalafil, prostaglandin E1 injection, device or prosthesis
    Vaginal drynessVaginal lubricants
Bladder dysfunction
    Frequency, urgency, nocturia, urinary retention, incontinenceCystometrogram, postvoiding sonographyBethanechol, intermittent catheterization
Sudomotor (sweating) dysfunction
    Anhidrosis, heat intolerance, dry skin, hyperhidrosisQuantitative sudomotor axon reflex, sweat test, skin blood flowEmollients and skin lubricants, scopolamine, glycopyrrolate, botulinum toxin, vasodilators
Pupillomotor
    Visual blurring, impaired adaptation to ambient light, impaired visceral sensationPupillometry, HRVCare with driving at night, recognition of unusual presentations of myocardial infarction