Q 58In adults with Type 1 diabetes, what are the symptoms suggestive of a diagnosis of autonomic neuropathy?

Author/Title/Reference/YrEwing, D. J. & Clarke, B. F. 1986, “Autonomic neuropathy: its diagnosis and prognosis.”, Clin Endocrinol Metab, vol. 15, no. 4, pp. 855–888.
N=Over 170 references
Research DesignReview
AimTo review the diagnosis and prognosis of autonomic neuropathy
PopulationNot specific to Type 1 diabetes
OutcomeDiagnosis of Autonomic neuropathy
ResultsAutonomic nerve damage can be found in many people with diabetes without an manifest symptoms being present
As autonomic symptoms are often vague and can present insidiously the majority of autonomic neuropathy in people with diabetes may go unrecognised for a considerable time
Symptoms may be attributed to the diabetes itself an thus can be interpreted incorrectly
A mixed presentation is usual, with a variable combination of postural hypotension, nocturnal diarrhoea, gastric problems, bladder symptoms, abnormal sweating, impotence, or a failure to recognise hypoglycaemia
People with severe symptoms may have advanced retinopathy, nephropathy, and somatic neuropathy
Diagnosis by symptoms may be patchy due to the variability of the clinical features
Hierarchy of Evidence GradingIV
CommentsShort section on clinical presentations as part of a wider review including tests
Many cited references 30+ years old
Author/Title/Reference/YrLevitt, N. S., Stansberry, K. B., Wynchank, S., & Vinik, A. I. 1996, “The natural progression of autonomic neuropathy and autonomic function tests in a cohort of people with IDDM”, Diabetes Care, vol. 19, no. 7, pp. 751–754.
N=76 People recruited consecutively over 3 months from a hospital diabetes clinic in 1981
Research DesignFollow up study
AimPeople with diabetes followed up for progression of Autonomic symptoms and cardiovascular autonomic neuropathy measures over 9 years
PopulationType I diabetes
InterventionSymptoms of autonomic neuropathy were assessed by a standard questionnaire, covering gastroparesis, diarrhoea, impotence, loss of vaginal lubrication, hypoglycaemic unawareness, and postural hypotension
Progression of clinical symptoms of autonomic neuropathy were analysed using chi squared test
Outcome5 standard cardiovascular tests were performed to determine cardiac autonomic neuropathy, including R-R ration, changes in heart rate with deep breathing, R-R variation with the Valsalva manoeuvre, response to blood pressure of sustained hand grip, and resting heart rate.
CharacteristicsMale =57%, Age =28.5 yrs, Duration of diabetes =4.6 yrs
ResultsAll of the cardiac function tests were worse in people who died in the 9 year follow up than survivors
Of the autonomic symptoms recorded only symptoms of gastroparesis progressed significantly over the study period, with only 1 person reporting symptoms at baseline and in 8 people at 9 years with no recoveries reported (p less than 0.01)
The following symptoms of autonomic neuropathy occurred at 9 years: gastroparesis (13%), diarrhoea (2%), impotence (7%), loss of vaginal lubrication (9%), hypoglycaemic unawareness (8%), and postural hypotension (2%).
There is a tendency for some symptoms such as hypoglycaemic unawareness to recover.
There was no correlation of the onset of gastroparesis with any of the tests of autonomic function
Hierarchy of Evidence GradingIV
CommentsFocusing on cardiac autonomic neuropathy
Author/Title/Reference/YrRyder, R. E. J., Dent, M. T., & Ward, J. D. 1992, “Testing for diabetic neuropathy, part two: Autonomic neuropathy”, Practical Diabetes, vol. 9, no. 2, pp. 56–60.
N=53 references
Research DesignReview
AimTo review testing for autonomic neuropathy
PopulationNot specific to Type 1 diabetes
OutcomeDiagnosis of Autonomic neuropathy
ResultsSymptomatic autonomic neuropathy is relatively uncommon, but is associated with poor prognosis
Symptoms which may be due to autonomic neuropathy in people with diabetes include: impotence, unexplained diarrhoea, faecal incontinence, unexplained urinary symptoms e.g. increased period between micturition, muted sensation of bladder fullness, frequency, urinary incontinence, unexplained bladder dilation, postural dizziness or faintness, gustatory sweating, dry feet, unexplained bloating, early satiety, fullness, nausea, vomiting, unexplained dysphagia, unexplained ankle oedema.
Tests for autonomic neuropathy may help support or counter possible neuropathic aetiology
Hierarchy of Evidence GradingIV
CommentsA review focusing on tests for autonomic neuropathy in people with diabetes, but mention of symptoms in introduction
Symptoms of diabetic autonomic neuropathy referenced to a book chapter

From: Appendix D, Evidence tables

Cover of Type 1 Diabetes in Adults
Type 1 Diabetes in Adults: National Clinical Guideline for Diagnosis and Management in Primary and Secondary Care.
NICE Clinical Guidelines, No. 15.1.
National Collaborating Centre for Chronic Conditions (UK).
Copyright © 2004, Royal College of Physicians of London.

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