Diabetic Autonomic Neuropathy

Last updated Feb. 27, 2017

What are the other Names for this Condition? (Also known as/Synonyms)

  • Autonomic Nerve Disease owing to Diabetes
  • DAN (Diabetic Autonomic Neuropathy)
  • Diabetic Autonomic Nerve Disease

What is Diabetic Autonomic Neuropathy? (Definition/Background Information)

Diabetic Neuropathy is a type of nerve damage that affects individuals who have diabetes. The term neuropathy indicates nerve dysfunction causing symptoms such as weakness and loss of sensation.

There are four types of Diabetes-Related Neuropathy. These include:

  • Diabetic Peripheral Neuropathy
  • Diabetic Autonomic Neuropathy
  • Diabetic Proximal Neuropathy
  • Diabetic Focal Neuropathy

Diabetic Autonomic Neuropathy (DAN) may not be termed as a single disorder, but a group of symptoms affecting multiple organs. The autonomic nervous system regulates involuntary movements in the body, such as those involved in heart function and digestion.

  • Diabetic Autonomic Neuropathy develops as a result of uncontrolled high blood sugar. Poor glycemic control could damage nerves that transmit signals from the brain and spinal cord to various parts of the body
  • The various parts that may be affected could include the stomach, bladder, sweat glands, blood vessels, heart, and eyes. Therefore, DAN could affect the digestive system (especially the stomach), urinary system, blood vessels, sex organs, and many other regions of the body
  • Symptoms could include bloating, nausea, vomiting, heartburn, feeling full after small meals, constipation, diarrhea, heat intolerance, altered sweating, and dizziness
  • Men may not be able to have or keep an erection; the symptoms may also include “dry” or reduced ejaculations. In women, vaginal lubrication may be affected. The affected women may also have fewer or no orgasms
  • Medications and changes to one’s dietary habits may help alleviate the symptoms

Who gets Diabetic Autonomic Neuropathy? (Age and Sex Distribution)

  • Individuals with non-insulin dependent diabetes mellitus (NIDDM) appear to have an earlier onset of Diabetic Autonomic Neuropathy symptoms than those with insulin-dependent diabetes mellitus (IDDM)
  • The symptoms of neuropathy are more prevalent in those with type 2 diabetes
  • Prevalence of Diabetic Neuropathy is reported to increase the longer an individual has had diabetes. About 2% of diabetic children have Autonomic Neuropathy
  • It has been reported that men develop Autonomic Neuropathy symptoms earlier than women. Though, according to a study conducted in the United Kingdom, the symptoms of DAN are more prevalent in women
  • African-Americans and Native-Americans develop Diabetic Autonomic Neuropathy earlier than Caucasians. When compared to Europeans, Asian Indians have a lower risk of developing neuropathy. However, despite a lower risk of developing neuropathy associated with diabetes, the South Asians are reported to have more painful symptoms

What are the Risk Factors for Diabetic Autonomic Neuropathy? (Predisposing Factors)

Any individual with diabetes may develop Diabetic Autonomic Neuropathy. However, the following factors could make one more susceptible to nerve damage:

  • Poor glycemic control
  • The time period (years) one has had diabetes
  • Poor body weight management, obesity
  • Racial preference: African and native Americans appear to be more susceptible to DAN
  • Hypertension
  • Smoking
  • Diabetic nephropathy (or diabetic kidney disease) is a risk factor, as it could lead to toxin build-up in blood. These toxins could potentially affect the nervous system

It is important to note that having a risk factor does not mean that one will get the condition. A risk factor increases ones chances of getting a condition compared to an individual without the risk factors. Some risk factors are more important than others.

Also, not having a risk factor does not mean that an individual will not get the condition. It is always important to discuss the effect of risk factors with your healthcare provider.

What are the Causes of Diabetic Autonomic Neuropathy? (Etiology)

The following factors may be responsible for Autonomic Neuropathy due to Diabetes:

  • Poor glycemic control is a key factor contributing to Diabetic Autonomic Neuropathy. High blood sugar over an extended period of time could cause nerve damage
  • Smoking, which has been proved to be a causative agent for diabetes, could also lead to narrowing of the blood vessels, thereby restricting blood flow. Poor circulation could lead to peripheral nerve dysfunction
  • Heavy alcohol consumption is known to be a cause of Autonomic Neuropathy
  • Some studies have shown unique gene expression profiles in individuals with Diabetic Neuropathy. Thus, genes related or unrelated to diabetes, could potentially contribute to nerve damage
  • Nerve inflammation, as a response to an autoimmune disorder in the individual affected by diabetes, could also lead to Autonomic Neuropathy

What are the Signs and Symptoms of Diabetic Autonomic Neuropathy?

The signs and symptoms of Diabetes-Related Autonomic Neuropathy are as follows:

  • Inability to understand drop in blood sugar levels in oneself
  • Gastroparesis: Digestive symptoms such as bloating, nausea, heartburn, and a poor absorption of food
  • A feeling of fullness after small meals and constipation
  • Vomiting undigested food
  • Diabetic diarrhea that could result from malfunction of the small intestine
  • Bladder symptoms may include bloating, trouble emptying the bladder, incontinence (leaking urine), frequent bathroom trips at night, etc.
  • The blood pressure of the affected individual might change
  • Increased resting heart rate
  • Sweat changes
  • Light-headedness or dizziness
  • Sexual health may be affected in both men and women:
    • In men, an inability to have or hold erections, along with “dry” or reduced ejaculations
    • Women may have fewer or no orgasms; also the vaginal lubrication may be affected

How is Diabetic Autonomic Neuropathy Diagnosed?

Diabetic Autonomic Neuropathy is difficult to diagnose, as the condition could potentially affect several organs. A healthcare provider may diagnose Diabetic Neuropathy after carefully evaluating the individual based on their medical history, duration of diabetes, glycemic control, and symptoms reported.

Based on an individual’s symptoms, a physician may require one or a combination of the following tests to be performed, in order to arrive at an accurate diagnosis after ruling out other medical conditions that might have similar symptoms:

  • Blood tests that include fasting plasma glucose, hemoglobin A1c, and complete blood count (CBC)
  • Electrolytes and liver panel (complete metabolic panel)
  • Genetic screens
  • Sequential multiple analysis-7 (renal function and electrolyte imbalances)
  • Ultrasound imaging of the bladder
  • Gastric emptying test to assess the rate at which food is being emptied by the stomach
  • An electromyography (EMG) test in conjunction with NCV test to see how well the muscles receive signals from the nerves
  • If an individual is suspected of having Autonomic Neuropathy, the physician may request special tests to observe blood pressure in different positions, as well as assess the individual’s ability to sweat

Many clinical conditions may have similar signs and symptoms. Your healthcare provider may perform additional tests to rule out other clinical conditions to arrive at a definitive diagnosis.

What are the possible Complications of Diabetic Autonomic Neuropathy?

Autonomic Neuropathy due to Diabetes affects involuntary muscle movements such as those of the heart and digestive functions. Malfunction of the circulatory and digestive systems could impact a number of other organs in the body potentially resulting in one or many of the following complications:

  • Sweating issues: The improper functioning of sweat glands with DAN could result in one’s inability to regulate body temperature. Overactive sweat glands could lead to night-time sweating or sweating while eating food (gustatory sweating)
  •  Digestive system related signs and symptoms: Nausea, constipation, diarrhea, alternating constipation/diarrhea, bloating, and other signs and symptoms, could lead to improper nutrition and therefore, could contribute to poor glycemic control
  • Urinary bladder related conditions:
    • Nerve damage could lead to loss of muscle control in the bladder. Leaking of urine or urinary incontinence could be the result of this complication
    • Nerve damage to the bladder could result in incomplete emptying of the bladder, which could potentially lead to bacterial build-up and therefore to urinary tract infections (UTIs)
  • Cardiac autonomic neuropathy (CAN): CAN is a significant factor in morbidity and mortality in diabetic patients without proper glycemic control. The resultant poor circulation could lead to a sharp drop in blood pressure, specifically when a patient stands up from a sitting position (orthostatic hypotension) leading to dizziness or fainting spells. Arrhythmia (improper heart beats) and tachycardia (abnormally fast beating of the heart) are also frequently observed in individuals affected by DAN
  • Inability to notice symptoms of hypoglycemia or low blood sugar: When the blood sugar levels drop too low, individuals suffering from Diabetic Neuropathy may be unable to notice symptoms such as trembling, sweating, or a rapid heart beat
  • Sexual dysfunction:
    • Erectile dysfunction in men
    • Lack of vaginal lubrication and orgasms in women

How is Diabetic Autonomic Neuropathy Treated?

Diabetic Autonomic Neuropathy occurs because of nerve damage following prolonged poor glycemic control and has no known cure. However, treatment options could be carefully chosen to ease pain, slow the progression of disease and reduce or manage the complications.

  • Digestive problems: Eating smaller meals more frequently or taking soups/semi-solid foods are known to relieve symptoms of bloating, nausea, and other conditions. Medications could be used to manage nausea, constipation, and diarrhea.  Sometimes, a physician may recommend medicines, such as fludrocortisone, to aid the body in retention of fluid and salt. A patient may be advised to sleep with the head raised to help with ease symptoms of nausea and heartburn
  • Urinary tract disorders: For bladder control, a physician may recommend using antispasmodic medications (anticholinergics). Following a timed urination could help one keep the bladder empty. In women, a device inserted into the vagina has been found to help in bladder control
  • Orthostatic hypotension: This condition could be managed by drinking plenty of fluids, reducing alcohol consumption, and avoiding standing up too quickly from a seated position. Physicians often recommend compression support for the abdomen. Compression stockings, which help increase blood flow, are also known to help with orthostatic hypotension. If a patient has irregular heartbeats as a result of nerve damage, a physician may prescribe suitable medication or a pacemaker to regulate the heart rhythm.
  • Sexual dysfunction:
    • Men: Medication for erectile dysfunction could help manage symptoms of sexual dysfunction, although such medications may not be effective or safe for every individual. Blood flow to the penis has been shown to increase with mechanical vacuum devices as well
    • Women: The use of lubricants could alleviate problems of vaginal dryness

How can Diabetic Autonomic Neuropathy be Prevented?

The following measures could help diabetics prevent or delay the onset of Diabetic Autonomic Neuropathy (DAN):

  • Maintaining good glycemic control: Following the recommended medication regimen and steadily maintaining blood sugar in the target range, go a long way in preventing or delaying neuropathy. Blood tests to check for A1c levels could help the patient and physician monitor blood sugar levels
  • Maintaining a healthy lifestyle: Avoiding a sedentary lifestyle and maintaining a healthy body weight play important roles in managing diabetes
  • Smoking cessation
  • Reducing alcohol consumption

What is the Prognosis of Diabetic Autonomic Neuropathy? (Outcomes/Resolutions)

  • Diabetic Autonomic Neuropathy has no known cure, since the mechanisms of this condition is poorly understood
  • At present, treatment options are available to alleviate pain and control some associated symptoms
  • Good glycemic control and a healthy lifestyle, in combination with proper vigilance, could help one avoid, delay, or manage the symptoms successfully

Additional and Relevant Useful Information for Diabetic Autonomic Neuropathy:

  • Type 2 diabetes is a chronic disease in which the blood contains high levels of glucose (sugar), the body’s main source of fuel

The following article link will help you understand type 2 diabetes:

http://www.dovemed.com/type-2-diabetes-2/

What are some Useful Resources for Additional Information?

American Diabetes Association
1701 North Beauregard St. Alexandria, VA 22311
Phone: (800) 342-2383
Email: AskADA@diabetes.org
Website: http://www.diabetes.org

National Institute of Diabetes and Digestive and Kidney Disorders (NIDDK)
Office of Communications and Public Liaison
Building 31, Room 9A04 Center Drive, MSC 2560
Phone: (301) 496-3583
Fax: (410) 689-3998
Email: NDDIC@info.niddk.nih.gov
Website: http://www.niddk.nih.gov

European Foundation for the Study of Diabetes (EFSD)
Rheindorfer Weg 3, 40591 Düsseldorf, Germany
Phone: +49 211 7584690
Fax: +49 211 75846929
Email: foundation@easd.org
Website: http://www.europeandiabetesfoundation.org

International Diabetes Federation (IDF)
166 Chaussee de La Halpe, B-1170 Brussels, Belgium
Phone: +32-2-538 55 11
Fax: +32-2-538 51 14
Website: http://www.idf.org

Diabetic Association of India
SL Raheja Hospital, Raheja Rugnalaya Marg, Mahim West, Mumbai 400 016, India
Phone: 91-022-66529999-9653
Fax: 91-022-24449418
Email: info@dairaheja.org
Website: http://www.dairaheja.org

References and Information Sources used for the Article:

National Diabetes Information Clearinghouse (NDIC). (n.d.). Retrieved June 3, 2015, from http://diabetes.niddk.nih.gov/dm/pubs/neuropathies/

(n.d.). Retrieved June 3, 2015, from http://www.neuropathy.org/site/DocServer/Diabetic_Neuropathies.pdf?docID=946

Autonomic Neuropathy. (n.d.). Retrieved June 13, 2015, from http://www.diabetes.org/living-with-diabetes/complications/neuropathy/autonomic-neuropathy.html

Diabetic Neuropathy (Nerve Damage) - An Update. (n.d.). Retrieved June 12, 2015, from http://www.joslin.org/info/diabetic_neuorpathy_nerve_damage_an_update.html

Autonomic Neuropathy. (n.d.). Retrieved June 12, 2015, from http://www.diabetes.org/living-with-diabetes/complications/neuropathy/autonomic-neuropathy.html

http://www.mayoclinic.org/diseases-conditions/diabetic-neuropathy/basics/definition/con-20033336 (accessed on June 13, 2015)

Smoking and Diabetes. (2015, March 13). Retrieved June 3, 2015, from http://www.cdc.gov/tobacco/campaign/tips/diseases/diabetes.html

Autonomic neuropathy: MedlinePlus Medical Encyclopedia. (n.d.). Retrieved June 12, 2015, from http://www.nlm.nih.gov/medlineplus/ency/article/000776.htm

Helpful Peer-Reviewed Medical Articles:

Aaberg, M., Burch, D., Hud, Z., & Zacharias, M. (2008). Gender differences in the onset of diabetic neuropathy. Journal of Diabetes and Its Complications, 22(2), 83-87. 

Young, B., Maynard, C., & Boyko, E. (2003). Racial Differences in Diabetic Nephropathy, Cardiovascular Disease, and Mortality in a National Population of Veterans. Diabetes Care, 26(8), 2392-2399. 

Abbott, C., Chaturvedi, N., Malik, R., Salgami, E., Yates, A., Pemberton, P., & Boulton, A. (2010). Explanations for the Lower Rates of Diabetic Neuropathy in Indian Asians Versus Europeans. Diabetes Care, 33(6), 1325-1330. 

Abbott, C., Malik, R., Ross, E., Kulkarni, J., & Boulton, A. (2011). Prevalence and Characteristics of Painful Diabetic Neuropathy in a Large Community-Based Diabetic Population in the U.K. Diabetes Care, 34(10), 2220-2224. 

Hur, J., Sullivan, K., Pande, M., Hong, Y., Sima, A., Jagadish, H., . . . Feldman, E. (2011). The identification of gene expression profiles associated with progression of human diabetic neuropathy. Brain, 134, 3222-3235.

Pop-Busui, R. (2010). Cardiac Autonomic Neuropathy in Diabetes: A clinical perspective. Diabetes Care, 33(2), 434-441.

Reviewed and Approved by a member of the DoveMed Editorial Board
First uploaded: June 18, 2015
Last updated: Feb. 27, 2017

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