Page 101 - The lraternational Journal of the Royal Society of Thailand.indd

The International Journal of the Royal Society of Thailand
Volume XV-2023

of other microvascular complications, particularly kidney disease and diabetic
peripheral neuropathy. Screening can include asking about orthostatic dizziness,
syncope, or dry cracked skin in the extremities. Signs of autonomic neuropathy include
orthostatic hypotension, a resting tachycardia, or evidence of peripheral dryness or
cracking of skin (ElSayed et al, 2023). Certain investigations and exclusion of other

potential etiologies are required prior to the diagnosis of autonomic neuropathy in
each organ.

Management of diabetic autonomic neuropathy
The treatment depends on the specific subtype. Optimization of glucose control

early in the course of type 1 diabetes mellitus (T1DM) is recommended to prevent or
delay CAN, whereas targeting all metabolic risk factors is the recommendation for
type 2 diabetes mellitus (T2DM). Volume repletion, physical activity, low-dose
fludrocortisone or midodrine and compression stockings are among treatment options
for CAN in patients with T1DM or T2DM.

Regarding gastrointestinal autonomic dysfunction, other causes should also be
excluded particularly side effects from opioids or diabetic medication (glucagon-like
peptide 1 receptor agonists) and other surgical conditions. Metoclopramide can be
used for short term symptomatic treatment for gastroparesis. The management of
diabetic gastroparesis is guided by the severity of symptoms, the magnitude of delayed

GE, and the nutritional status. Initial options include dietary modifications,
supplemental oral nutrition, and antiemetic and prokinetic medications. Patients with
more severe symptoms may require a venting gastrostomy or jejunostomy and/or

gastric electrical stimulation. Promising newer therapeutic approaches include ghrelin
receptor agonists and selective 5-hydroxytryptamine receptor agonists (Bharucha
et al, 2019).

Routine screening and exclusion of other causes are recommended in patients
with urogenital autonomic neuropathy. Pharmacological treatment of male erectile

dysfunction includes phosphodiesterase type 5 inhibitors such as sildenafil and
tadalafil. Adequate skin moisturizer can provide relief for dry skin and prevention of
chronic wound.

Conclusion

Distal symmetric sensorimotor axonal polyneuropathy and autonomic neuropathy
are common in diabetic patients. Routine screening during treatment can lead to early
diagnosis. Multiple mechanisms are proposed for its pathogenesis. Optimization of
glucose control and management of other vascular risk factors are also recommended.

Kongkiat Kulkantrakorn 93