Summary
Definition
History and exam
Key diagnostic factors
- asymptomatic
- pain (peripheral)
- loss of sensation (peripheral)
- dysesthesia (peripheral)
- reduced or absent ankle reflexes (peripheral)
- painless injuries (peripheral)
- resting tachycardia (autonomic)
- impaired heart rate variability (autonomic)
- urinary frequency, urgency, nocturia, incontinence, hesitancy, weak stream, or retention (autonomic)
- erectile dysfunction (autonomic)
- decreased sexual desire and increased pain during intercourse (autonomic)
- orthostatic hypotension (autonomic)
Other diagnostic factors
- constipation (autonomic)
- fecal incontinence (autonomic)
- anhidrosis, heat intolerance, dry skin, or hyperhidrosis (autonomic)
- hypoglycemia unawareness (autonomic)
- weakness (peripheral)
- history of recent falls (peripheral)
- gait ataxia (peripheral)
- nausea, postprandial vomiting, bloating, loss of appetite, early satiety (autonomic)
- heartburn and dysphagia for solids (autonomic)
- profuse and watery diarrhea (autonomic)
- specific mononeuropathy (peripheral)
- cranial neuropathy (peripheral)
- pain over lower thoracic or abdominal wall (peripheral)
- thigh muscle atrophy, pain, and weakness (peripheral)
Risk factors
- poorly controlled hyperglycemia
- prolonged duration of diabetes
- older age (e.g., >70 years)
- tall stature
- hypertension
- dyslipidemia with elevated triglycerides
- co-existence of multiple cardiovascular disease (CVD) risk factors (type 2 diabetes)
- obesity
- immune dysregulation
- smoking
Diagnostic investigations
1st investigations to order
- clinical diagnosis
- fasting blood glucose
- HbA1c
- serum thyroid-stimulating hormone
- serum vitamin B12
- electrolytes, BUN, creatinine
- serum lipid profile
- LFTs
- CBC and erythrocyte sedimentation rate
- serum/urine immunoelectrophoresis
- corneal confocal microscopy
Investigations to consider
- oral glucose tolerance test
- nerve conduction studies (nerve conduction velocity [NCV])
- electromyography (EMG)
- quantitative sensory testing (QST)
- skin biopsy
- cardiovascular reflex testing
- heart rate variability (HRV)
- gastric emptying studies
- gastroduodenoscopy
- surface electrogastrography
- barium meal
- gastrointestinal manometry
- hydrogen breath tests
- gastric ultrasonography
- gastric MRI
- anorectal manometry
- fecal fat
- d-xylose test
- urine culture
- cystometry, voiding cystometrogram
- postvoid urinary tract ultrasound
- video-urodynamics
- measurement of nocturnal penile tumescence and of penile and brachial BP
- serum LH, testosterone, free testosterone, prolactin (morning tests, 8.00-9.00 a.m.)
- sudomotor function tests
- scintigraphic studies
- assessment of sympathetic muscle activity
- cardiac vagal baroreflex sensitivity testing
- 24-hour BP profile
- microneurography
Treatment algorithm
Contributors
Authors
Professor of Medicine
Organizational Official for the Human Research Protection Program
Weill Cornell Medicine - Qatar
Doha
Qatar
Disclosures
RAM is on speaker panels for Eli Lilly, Novo Nordisk, and Pfizer; he is on advisory boards for Novo Nordisk and Pfizer. RAM is an author of references cited in this topic.
Senior Lecturer and Consultant Physician
University of Liverpool
Liverpool
UK
Disclosures
UA serves on advisory boards for Eli Lilly.
Consultant Physician
Diabetes and Endocrinology
Central Manchester Foundation Trust
University of Manchester
Manchester
UK
Disclosures
SA declares that she has no competing interests.
Dr Rayaz Malik, Dr Uazman Alam, and Dr Shazli Azmi would like to gratefully acknowledge Dr Rodica Pop-Busui and Dr Eva Feldman, the previous contributors to this topic.
Disclosures
RPB declares that she has received speaking honoraria from Pfizer and research support from Amylin Pharmaceuticals; National Institutes of Health/National Heart, Lung, and Blood Institute; National Institute of Health/National Institute of Diabetes and Digestive and Kidney Diseases; American Diabetes Association; and Juvenile Diabetes Research Foundation. RPB and EF are authors of references cited in this topic.
Peer reviewers
Clinical Professor
Department of Medicine
Mount Sinai School of Medicine
New York
NY
Disclosures
ZTB declares that he has no competing interests.
Assistant Professor of Medicine
Harvard Medical School
Division of Endocrinology
Diabetes and Hypertension
Brigham and Women's Hospital
Boston
MA
Disclosures
RKG has received consultant fees from Aventis and Novartis, and speaker fees from Novartis.
Consultant and Honorary Senior Lecturer
Tameside General Hospital
Diabetes Centre
Ashton Under Lyne
Lancashire
UK
Disclosures
EJ has received funding for conferences and lectures from Pfizer and Boehringer Ingelheim.
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