FFinalistSouthampton · 2027
Neurology
AKT · Neurology/Cord & peripherallow yield

Autonomic neuropathy

Damage to autonomic nerves (commonly diabetes)

Overview

Dysfunction of the autonomic nervous system, most commonly from long-standing diabetes. Produces postural hypotension, gastrointestinal dysmotility, bladder dysfunction and other autonomic features — often alongside a peripheral sensory neuropathy. Management is largely symptomatic.

Recognise

  • Postural (orthostatic) hypotension — dizziness/syncope on standing
  • GI: gastroparesis (early satiety, vomiting), constipation/diarrhoea; bladder dysfunction; erectile dysfunction
  • Causes: diabetes (commonest), amyloidosis, Parkinson-plus (MSA), Guillain-Barré, alcohol

Red flags

  • Symptomatic postural hypotension with falls; severe gastroparesis; coexisting cardiac autonomic involvement

Differentials & how to tell them apart

Multiple system atrophy (MSA)autonomic failure + parkinsonism/cerebellar signs, poor levodopa response
Drug-induced postural hypotensionantihypertensives, alpha-blockers — review medications
Addison disease / hypovolaemiaother causes of postural drop
Pure autonomic failureisolated autonomic degeneration

Investigations

Lying/standing BP (postural drop), autonomic function tests; identify the cause (glucose/HbA1c, exclude amyloid/MSA).

Management

Treat the cause + symptomatic management (postural-BP measures, prokinetics, bladder care)

  1. 1Confirm with lying/standing BP and identify the cause (commonly diabetes). Manage postural hypotension non-pharmacologically first (slow standing, compression, salt/fluids), then fludrocortisone/midodrine.Gate: Review and reduce drugs that worsen postural hypotension (antihypertensives, alpha-blockers, diuretics) before adding pressor agents
  2. 2Symptom-specific treatment (prokinetics for gastroparesis, bladder management); optimise diabetic control; consider MSA if parkinsonism/cerebellar signs.
Symptomatic — fludrocortisone/midodrine (postural hypotension), prokinetics (gastroparesis), bladder measures

Key points

Postural hypotension + GI/bladder dysfunction in a long-standing diabetic = autonomic neuropathy. Autonomic failure + parkinsonism that responds poorly to levodopa points to MSA instead.

Monitor & prognosis

Postural BP, symptoms, glycaemic control, medication review.

Depends on the cause; symptomatic measures help.

Source: NICE CKS (diabetes - autonomic); neurology