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Table 4—

Treatment of autonomic neuropathy

SymptomsTestsTreatments
Cardiac   
    Exercise intolerance, early fatigue and weakness with exercise HRV, multigated angiography (MUGA) thallium scan, 123I metaiodobenzlyguanidine (MIBG) scan Graded supervised exercise, ACE inhibitors, β-blockers 
    Postural hypotension, dizziness, lightheadedness, weakness, fatigue, syncope HRV, measure blood pressure standing and supine, measure catecholamines Mechanical measures, clonidine, midodrine, octreotide 
Gastrointestinal   
    Gastroparesis, erratic glucose control Gastric emptying study, barium study Frequent small meals, prokinetic agents (metoclpramide, domperidone, erythromycin) 
    Abdominal pain or discomfort, early satiety, nausea, vomiting, belching, bloating Endoscopy, manometry, electrogastrogram Antibiotics, antiemetics (phenergan, compazine, tigan, scopolamine), bulking agents, tricyclic antidepressants, pancreatic extracts, pyloric Botox, gastric pacing, enteral feeding 
    Constipation Endoscopy High-fiber diet and bulking agents, osmotic laxatives, lubricating agents and prokinetic agents used cautiously 
    Diarrhea, often nocturnal alternating with constipation and incontinence  Trials of soluble fiber, gluten and lactose restriction, anticholinergic agents, cholestyramine, antibiotics, clonidine, somatostatin, pancreatic enzyme supplements 
Sexual dysfunction   
    Erectile dysfunction History and physical examination, HRV, penile-brachial pressure index, nocturnal penile tumescence Sex therapy, psychological counseling, sildenafil, vardenafil, tadalafil, prostaglandin E1 injection, device or prosthesis 
    Vaginal dryness  Vaginal lubricants 
Bladder dysfunction   
    Frequency, urgency, nocturia, urinary retention, incontinence Cystometrogram, postvoiding sonography Bethanechol, intermittent catheterization 
Sudomotor (sweating) dysfunction   
    Anhidrosis, heat intolerance, dry skin, hyperhidrosis Quantitative sudomotor axon reflex, sweat test, skin blood flow Emollients and skin lubricants, scopolamine, glycopyrrolate, botulinum toxin, vasodilators 
Pupillomotor   
    Visual blurring, impaired adaptation to ambient light, impaired visceral sensation Pupillometry, HRV Care with driving at night, recognition of unusual presentations of myocardial infarction 
SymptomsTestsTreatments
Cardiac   
    Exercise intolerance, early fatigue and weakness with exercise HRV, multigated angiography (MUGA) thallium scan, 123I metaiodobenzlyguanidine (MIBG) scan Graded supervised exercise, ACE inhibitors, β-blockers 
    Postural hypotension, dizziness, lightheadedness, weakness, fatigue, syncope HRV, measure blood pressure standing and supine, measure catecholamines Mechanical measures, clonidine, midodrine, octreotide 
Gastrointestinal   
    Gastroparesis, erratic glucose control Gastric emptying study, barium study Frequent small meals, prokinetic agents (metoclpramide, domperidone, erythromycin) 
    Abdominal pain or discomfort, early satiety, nausea, vomiting, belching, bloating Endoscopy, manometry, electrogastrogram Antibiotics, antiemetics (phenergan, compazine, tigan, scopolamine), bulking agents, tricyclic antidepressants, pancreatic extracts, pyloric Botox, gastric pacing, enteral feeding 
    Constipation Endoscopy High-fiber diet and bulking agents, osmotic laxatives, lubricating agents and prokinetic agents used cautiously 
    Diarrhea, often nocturnal alternating with constipation and incontinence  Trials of soluble fiber, gluten and lactose restriction, anticholinergic agents, cholestyramine, antibiotics, clonidine, somatostatin, pancreatic enzyme supplements 
Sexual dysfunction   
    Erectile dysfunction History and physical examination, HRV, penile-brachial pressure index, nocturnal penile tumescence Sex therapy, psychological counseling, sildenafil, vardenafil, tadalafil, prostaglandin E1 injection, device or prosthesis 
    Vaginal dryness  Vaginal lubricants 
Bladder dysfunction   
    Frequency, urgency, nocturia, urinary retention, incontinence Cystometrogram, postvoiding sonography Bethanechol, intermittent catheterization 
Sudomotor (sweating) dysfunction   
    Anhidrosis, heat intolerance, dry skin, hyperhidrosis Quantitative sudomotor axon reflex, sweat test, skin blood flow Emollients and skin lubricants, scopolamine, glycopyrrolate, botulinum toxin, vasodilators 
Pupillomotor   
    Visual blurring, impaired adaptation to ambient light, impaired visceral sensation Pupillometry, HRV Care with driving at night, recognition of unusual presentations of myocardial infarction 
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