Clinical Commandments for Management of Patients With
Type 2 Diabetes

Autonomic Neuropathy

Saul M. Genuth, MD
Professor of Medicine
Case Western Reserve University School of Medicine
Chief of Endocrinology
Mt Sinai Medical Center
Cleveland, Ohio

Nerve damage is one of the most common complications in patients with type 2 diabetes, occurring in up to 50% of these patients over the course of their disease.

Neuropathies in type 2 diabetes are usually autonomic or peripheral. Although peripheral neuropathies are more common, autonomic neuropathies, because they involve involuntary actions, may exact a more profound toll on patient quality of life.

In patients with diabetes and autonomic neuropathy, the clinician may encounter the following: gastroparesis (indicated by postprandial hypoglycemia after insulin lispro or regular insulin injection); alternating bouts of diarrhea-particularly nocturnal-and constipation (suggestive of diabetic enteropathy); frequent urinary tract infections (suggestive of diabetic cystopathy or neurogenic bladder); inability to empty the bladder; sexual dysfunction; postural hypotension; and decreased variation in heart rate in response to inspiration and expiration, change in posture, and/or the Valsalva maneuver. Among these, gastroparesis and sexual dysfunction are particularly troublesome for many patients.

Gastroparesis

Gastroparesis should be considered in patients who complain of an early sense of fullness and satiety or of feeling full or bloated after meals. Other presenting symptoms include heartburn caused by reflux, nausea, and vomiting of undigested food that had been eaten many hours earlier ("morning sickness"). Weight loss and gastrospasm are associated signs. Gastroparesis may contribute to poor metabolic control due to dyssynchrony between movement of food out of the stomach and absorption of preprandial injections of rapid-acting insulin. Early gastropathy can be managed with small, frequent feedings and with metoclopramide (10 mg tid 30 minutes before eating). Erythromycin 250 to 500 mg 30 minutes before eating is also sometimes effective. Referral to a dietitian may also be helpful. Good glucose control should always be established.

Sexual dysfunction

Nearly 50% of male patients with type 2 diabetes report some level of sexual dysfunction, usually characterized by inadequate, transient, or absent erections. Impotence due to neuropathy differs from psychogenic impotence in that the latter tends to be intermittent, whereas diabetic impotence is usually persistent.

External vacuum therapy, though cumbersome and off-putting to many, is a nonsurgical treatment option that has been accepted by some patients. Additionally, recent research indicates that the new agent Vigra® slidenafil may be useful in selected men with diabetes. Because diabetic impotence is usually permanent, a surgically implanted penile prosthesis may be considered as a last resort in very unhappy patients for whom nothing else gives satisfaction.

Although few studies of female sexual dysfunction exist, the results tend to confirm that this complication is also prevalent, found in up to 35% of women with type 2 diabetes. It is characterized by inhibited sexual excitement, lowered desire, dyspareunia, and decreases in physiologic measures (orgasmic capacity, lubrication) as well as psychosocial measures (sexual and partner satisfaction, frequency of sexual activity). In addition, women with diabetes who experience sexual dysfunction tend to be more depressed than counterparts with normal sexual function.

One factor complicating an accurate assessment of the contribution of diabetes to women's sexual dysfunction is the fact that the diagnosis of diabetes frequently occurs around the time of menopause. At present, recommended treatment includes patient counseling and local administration of estrogens, such as estriol vaginal creams or pessaries or the recently introduced estradiol-loaded vaginal ring. A program of pelvic floor (Kegel) exercises is also appropriate to manage the stress incontinence that often is present in this population.

Management strategies for all patients with type 2 diabetes should strive to prevent or arrest development and progression of neuropathic complications. Although the cause of diabetic autonomic neuropathy is not known, hyperglycemia may be the most significant factor in its development. The Diabetes Control and Complications Trial (DCCT) demonstrated that intensive treatment can slow the progression and development of autonomic dysfunction, as compared with conventional treatment.

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