How should I adjust the management plan for a patient with hypoglycaemia who is also experiencing symptoms of autonomic neuropathy?

Adjusting the management plan for a patient with hypoglycaemia who is also experiencing symptoms of autonomic neuropathy involves several key steps:

• Assess for impaired awareness of hypoglycaemia, which is common in autonomic neuropathy, and arrange referral to the specialist diabetes team for advice on management if suspected.
• Review and possibly adjust insulin regimens or other glucose-lowering therapies to reduce the risk of hypoglycaemia, considering factors such as insulin sensitivity changes and lifestyle patterns.
• Provide structured education focusing on hypoglycaemia awareness and management, including flexible insulin therapy and avoidance strategies.
• Consider additional interventions such as insulin pump therapy or real-time continuous glucose monitoring to better prevent hypoglycaemia in patients with impaired awareness.
• Be vigilant for symptoms of postural hypotension and other autonomic manifestations that may affect treatment choices, including careful use of antihypertensive drugs to avoid exacerbating hypotension.
• Address gastrointestinal symptoms like gastroparesis by advising a small-particle-size diet and considering referral for specialist treatment, as delayed gastric emptying can affect glucose absorption and hypoglycaemia risk.
• Monitor for other autonomic symptoms (e.g., bladder dysfunction, sweating abnormalities) and manage accordingly, involving specialist teams as needed.

Overall, the management plan should be individualized, with multidisciplinary input to address both hypoglycaemia and autonomic neuropathy comprehensively.

References: ¹,²,³,⁵