Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ONGOING

diabetic peripheral neuropathy

1st line – glycaemic control and supportive measures

Back
ONGOING
|
diabetic peripheral neuropathy
|
without pain
1st line – 

glycaemic control and supportive measures

There is some evidence for a reduction in risk of DN with optimal blood glucose control achieved using multiple insulin injections in people with type 2 diabetes, but the evidence is not as strong as that for type 1 diabetes.[34]

Lifestyle interventions (diet and exercise) are recommended as they may improve neuropathic symptoms and intra-epidermal nerve fibre density in patients with neuropathy and impaired glucose tolerance.[131][132]​​​ Treatment of other modifiable risk factors (e.g., obesity, lipids and blood pressure) may also be beneficial in patients with both type 1 and type 2 diabetes.[39]​​ Control of these modifiable risk factors (glucose, blood pressure, and lipids) in addition to adhering to a healthy lifestyle may prevent other associated microvascular complications of diabetes (retinopathy and nephropathy).​[39]

Proper care of the foot begins with educating the patient.[128] Minor non-infected wounds without evidence of soft-tissue or bone infection do not require antibiotic therapy. More serious problems are best handled in consultation with specialists in diabetic foot care.[92][93]

1st line – pregabalin or gabapentin and/or duloxetine plus glycaemic control and supportive measures

Back
ONGOING
|
diabetic peripheral neuropathy
|
with pain
1st line – 

pregabalin or gabapentin and/or duloxetine plus glycaemic control and supportive measures

Pregabalin, gabapentin, and duloxetine are considered first-line pharmacotherapies for painful DN.[1]​​[39]​​

Pregabalin has been found to decrease mean pain score in people with painful DN.[136] [ Cochrane Clinical Answers logo ] Unlike gabapentin, pregabalin may possibly be habit forming. It has been found to improve pain in some people with DN.[137] Adverse effects include somnolence, dizziness, peripheral oedema, and gait disturbance.

Clinical studies of duloxetine, a serotonin-noradrenaline reuptake inhibitor (SNRI), have found that it is safe and effective in the management of painful DN.[138] Duloxetine may be used alone or added to either pregabalin or gabapentin.[156]

Nausea can occur, but slow-dose titration and taking the drug with food can usually reduce or avoid this common adverse effect. Somnolence may also occur.[139]​ The ADA advises that referral to a neurologist or pain specialist may be indicated when pain control is not achieved with initial treatment, depending on the scope of practice of the treating physician.​[39]

There is some evidence for a reduction in risk of DN with optimal blood glucose control achieved using multiple insulin injections in people with type 2 diabetes, but the evidence is not as strong as that for type 1 diabetes.[34]

Lifestyle interventions (diet and exercise) are recommended as they may improve neuropathic symptoms and intra-epidermal nerve fibre density in patients with neuropathy and impaired glucose tolerance.[131][132]​​​ Treatment of other modifiable risk factors (e.g., obesity, lipids and blood pressure) may also be beneficial in patients with both type 1 and type 2 diabetes.[39] Control of these modifiable risk factors (glucose, blood pressure, and lipids) in addition to adhering to a healthy lifestyle may prevent other associated microvascular complications of diabetes (retinopathy and nephropathy).[39]​ The American Academy of Neurology also recommends cognitive behavioural therapy and mindfulness as potential options for patients with painful DN.[66]

Proper care of the foot begins with educating the patient.[128] Minor non-infected wounds without evidence of soft-tissue or bone infection do not require antibiotic therapy. More serious problems are best handled in consultation with specialists in diabetic foot care.[92][93]

Assess patient for comorbid mood disorders, particularly depression and anxiety, and sleep disorders.[24][66][101][102]​​[104][105]​​ The presence of sleep disorders or mood disorders can affect perception of pain; treatment may help reduce pain and improve quality of life.[66] Antidepressant treatment options for painful neuropathy may also have beneficial effects on mood disorders. Presence of mood disorders should be taken into account when selecting regimens.

Primary options

pregabalin: 50-100 mg orally three times daily initially, increase gradually according to response, maximum 600 mg/day

OR

gabapentin: 300 mg orally three times daily initially, increase by 300 mg/day increments at weekly intervals according to response, maximum 3600 mg/day

OR

duloxetine: 60 mg orally once daily

OR

pregabalin: 50-100 mg orally three times daily initially, increase gradually according to response, maximum 600 mg/day

and

duloxetine: 60 mg orally once daily

Secondary options

gabapentin: 300 mg orally three times daily initially, increase by 300 mg/day increments at weekly intervals according to response, maximum 3600 mg/day

and

duloxetine: 60 mg orally once daily

2nd line – antidepressant or sodium-channel blocker plus glycaemic control and supportive measures

Back
ONGOING
|
diabetic peripheral neuropathy
|
with pain
2nd line – 

antidepressant or sodium-channel blocker plus glycaemic control and supportive measures

Antidepressants may be used if there is no benefit from pregabalin or gabapentin and duloxetine. They may be used alone or in combination with pregabalin or gabapentin. The ADA advises that referral to a neurologist or pain specialist may be indicated when pain control is not achieved with initial treatment, depending on the scope of practice of the treating physician.​[39]

Tricyclic antidepressants act across multiple neurotransmitter pathways and may be effective in some patients.[39]​​[66][145][146]​​ In the UK, the National Institute of Health and Care Excellence (NICE) recommends amitriptyline as a first-line treatment option for neuropathic pain.[134] In contrast with NICE, Cochrane reviews do not support the use of amitryptyline, or other tricyclic antidepressants including nortriptyline, imipramine, or desipramine, as first-line treatments for painful DN.[147][148][149][150]​​ Studies assessing the efficacy of these agents were methodologically flawed and potentially subject to major bias. In clinical trials of tricyclic antidepressants, approximately 20% of participants withdrew because of intolerable adverse effects, such as sedation, confusion, and anticholinergic adverse effects. Combination treatment with amitriptyline and pregabalin has been assessed in trials and may be an option in some patients.[158]

A 2015 Cochrane review found little compelling evidence to support the use of the serotonin-noradrenaline reuptake inhibitor (SNRI) venlafaxine in neuropathic pain.[142] In the UK, NICE recommends against initiating venlafaxine for neuropathic pain unless advised by a consultant to do so.[134]

The selective serotonin-reuptake inhibitor (SSRI) paroxetine has been found to reduce symptoms.[153]

Sodium-channel blockers are not approved for the treatment of painful DN but may be effective in some patients.​[66] Agents in this class include carbamazepine and valproic acid derivatives. One Cochrane review found limited evidence to suggest that valproic acid or sodium valproate reduce pain in DN, and did not recommend these treatments as first-line therapy for neuropathic pain.[152] Valproic acid should not be prescribed for painful DN unless patients have failed treatment on multiple other agents, due to risk of serious adverse events such as hepatotoxicity, pancreatitis, hyponatraemia, and pancytopenia.[66] In the UK, NICE recommends against initiating sodium valproate for neuropathic pain unless advised by a consultant to do so.[134]

Valproic acid (and its derivatives) must not be used in female patients of child-bearing potential unless other options are unsuitable, there is a pregnancy prevention programme in place, and certain conditions are met. Precautionary measures may also be required in male patients owing to a potential risk that use in the 3 months leading up to conception may increase the likelihood of neurodevelopmental disorders in their children. Regulations and precautionary measures for female and male patients may vary between countries, with some countries taking a more heightened precautionary stance, and you should consult your local guidance for more information.

There is some evidence for a reduction in risk of DN with optimal blood glucose control achieved using multiple insulin injections in people with type 2 diabetes, but the evidence is not as strong as that for type 1 diabetes.[34]

Lifestyle interventions (diet and exercise) are recommended as they may improve neuropathic symptoms and intra-epidermal nerve fibre density in patients with neuropathy and impaired glucose tolerance.[131][132]​​​ Treatment of other modifiable risk factors (e.g., obesity, lipids and blood pressure) may also be beneficial in patients with both type 1 and type 2 diabetes.[39] Control of these modifiable risk factors (glucose, blood pressure, and lipids) in addition to adhering to a healthy lifestyle may prevent other associated microvascular complications of diabetes (retinopathy and nephropathy).​[39] The American Academy of Neurology also recommends cognitive behavioural therapy and mindfulness as potential options for patients with painful DN.[66]

Proper care of the foot begins with educating the patient.[128] Minor non-infected wounds without evidence of soft-tissue or bone infection do not require antibiotic therapy. More serious problems are best handled in consultation with specialists in diabetic foot care.[92][93]

Assess patient for comorbid mood disorders, particularly depression and anxiety, and sleep disorders.[24][66][101][102]​​​[104]​​[105]​ The presence of sleep disorders or mood disorders can affect perception of pain; treatment may help reduce pain and improve quality of life.[66] Antidepressant treatment options for painful neuropathy may also have beneficial effects on mood disorders. Presence of mood disorders should be taken into account when selecting regimens.

Primary options

amitriptyline: 10-25 mg orally once daily at bedtime initially, increase according to response, maximum 150 mg/day

OR

venlafaxine: 75-225 mg orally (extended-release) once daily

OR

imipramine: 10-25 mg orally once daily at bedtime initially, increase according to response, maximum 150 mg/day

OR

nortriptyline: 10-25 mg orally once daily at bedtime initially, increase according to response, maximum 150 mg/day

OR

desipramine: 25-75 mg orally once daily initially, increase dose according to response, maximum 150 mg/day

Secondary options

paroxetine: 40 mg orally once daily

Tertiary options

carbamazepine: consult specialist for guidance on dose

OR

valproic acid: consult specialist for guidance on dose

3rd line – topical therapies plus glycaemic control and supportive measures

Back
ONGOING
|
diabetic peripheral neuropathy
|
with pain
3rd line – 

topical therapies plus glycaemic control and supportive measures

The ADA advises that referral to a neurologist or pain specialist may be indicated when pain control is not achieved with initial treatment, depending on the scope of practice of the treating physician.​[39]

US guidelines advise that topical capsaicin may be effective in some patients when used alone or in combination with other therapies.[39]​​[66]​ Capsaicin is available as a topical cream or patch. In the UK, National Institute of Health and Care Excellence (NICE) guidelines state that capsaicin cream may be considered in a consultant setting for patients with localised neuropathic pain who wish to avoid, or who cannot tolerate, oral treatments.[134] A few small studies have demonstrated the effectiveness of topical capsaicin in control of pain and improvement in daily activities.[161] [ Cochrane Clinical Answers logo ] ​​​​ Poor adherence is common, due to the need for frequent applications, an initial exacerbation of symptoms, and frequent burning and redness at the application site.[145]

Glyceryl trinitrate spray is included in the AAN guidelines as an option for topical treatment as it is possibly more likely than placebo to improve pain.[66] Evidence from one small randomised controlled trial suggested that glyceryl trinitrate spray may have some efficacy when used alone and in combination with sodium valproate.[66][162]

A lidocaine topical patch is available in some countries for the management of post-herpetic neuralgia. There are limited data supporting the off-label use of lidocaine topical patches in diabetic peripheral neuropathy (DPN). They may be considered in individuals with nocturnal neuropathic foot pain; however, they are not effective if there is a more widespread distribution of pain.[163]

There is some evidence for a reduction in risk of DN with optimal blood glucose control achieved using multiple insulin injections in people with type 2 diabetes, but the evidence is not as strong as that for type 1 diabetes.[34]

Lifestyle interventions (diet and exercise) are recommended as they may improve neuropathic symptoms and intra-epidermal nerve fibre density in patients with neuropathy and impaired glucose tolerance.[131][132]​ Treatment of other modifiable risk factors (e.g., obesity, lipids and blood pressure) may also be beneficial in patients with both type 1 and type 2 diabetes.[39]​​ Control of these modifiable risk factors (glucose, blood pressure, and lipids) in addition to adhering to a healthy lifestyle may prevent other associated microvascular complications of diabetes (retinopathy and nephropathy).[39]​ The American Academy of Neurology also recommends cognitive behavioural therapy and mindfulness as potential options for patients with painful DN.[66]

Proper care of the foot begins with educating the patient.[128] Minor non-infected wounds without evidence of soft-tissue or bone infection do not require antibiotic therapy. More serious problems are best handled in consultation with specialists in diabetic foot care.[92][93]

Assess patient for comorbid mood disorders, particularly depression and anxiety, and sleep disorders.[24][66][101][102]​​​[104]​​[105]​ The presence of sleep disorders or mood disorders can affect perception of pain; treatment may help reduce pain and improve quality of life.[66] 

Primary options

capsaicin topical: (0.025% or 0.075%) apply to the affected area(s) up to four times daily when required; (8% patch) apply patch to most painful area(s) for 30 minutes and remove, maximum 4 patches per application, may repeat treatment after 3 months (do not apply more frequently than every 3 months)

Secondary options

glyceryl trinitrate: (0.4 mg/dose spray) consult specialist for guidance on dose

OR

lidocaine topical: (5% patch) apply patch to most painful area(s) for up to 12 hours per day, maximum 3 patches per application

4th line – TENS, PENS, or acupuncture plus glycaemic control and supportive measures

Back
ONGOING
|
diabetic peripheral neuropathy
|
with pain
4th line – 

TENS, PENS, or acupuncture plus glycaemic control and supportive measures

The ADA advises that referral to a neurologist or pain specialist may be indicated when pain control is not achieved with initial treatment, depending on the scope of practice of the treating physician.[39]​ Transcutaneous electrical nerve stimulation (TENS) or acupuncture may be added to existing therapy or used alone in refractory cases.[145][164]

In a controlled study, TENS was more effective than sham treatment in reducing pain in patients with DN.[165]

In uncontrolled studies, TENS and acupuncture have been reported to decrease pain in >75% of patients with DN.[166][167]

The UK National Institute for Health and Care Excellence found evidence of short-term efficacy of percutaneous electrical nerve stimulation (PENS) for refractory neuropathic pain with no major safety concerns. Treatment with PENS should involve specialists in pain management.[168]

There is some evidence for a reduction in risk of DN with optimal blood glucose control achieved using multiple insulin injections in people with type 2 diabetes, but the evidence is not as strong as that for type 1 diabetes.[34]

Lifestyle interventions (diet and exercise) are recommended as they may improve neuropathic symptoms and intra-epidermal nerve fibre density in patients with neuropathy and impaired glucose tolerance.[131][132]​​​ Treatment of other modifiable risk factors (e.g., obesity, lipids and blood pressure) may also be beneficial in patients with both type 1 and type 2 diabetes.[39]​ Control of these modifiable risk factors (glucose, blood pressure, and lipids) in addition to adhering to a healthy lifestyle may prevent other associated microvascular complications of diabetes (retinopathy and nephropathy).[39]​ The American Academy of Neurology also recommends cognitive behavioural therapy and mindfulness as potential options for patients with painful DN.[66]

Proper care of the foot begins with educating the patient.[128] Minor non-infected wounds without evidence of soft-tissue or bone infection do not require antibiotic therapy. More serious problems are best handled in consultation with specialists in diabetic foot care.[92][93]

Assess patient for comorbid mood disorders, particularly depression and anxiety, and sleep disorders.[24][66][101][102]​​​[104]​​[105]​ The presence of sleep disorders or mood disorders can affect perception of pain; treatment may help reduce pain and improve quality of life.[66] 

5th line – spinal cord stimulation plus glycaemic control and supportive measures

Back
ONGOING
|
diabetic peripheral neuropathy
|
with pain
5th line – 

spinal cord stimulation plus glycaemic control and supportive measures

The ADA advises that referral to a neurologist or pain specialist may be indicated when pain control is not achieved with initial treatment, depending on the scope of practice of the treating physician.​[39] Should be considered in patients refractory to all other treatment options for severe painful DN.[169][170]​​​ One systematic review and meta-analysis found that spinal cord stimulation is an effective therapeutic adjunct to best medical therapy in reducing pain intensity and improving health-related quality of life in patients with painful DN.[171] One systematic review and network meta-analysis found pain relief and health-related quality of life benefits of the addition of spinal cord stimulation to conventional medical management for patients with painful DN. Greater pain reductions were seen in those who received high-frequency spinal cord stimulation compared with those receiving low frequency.[172]

There is some evidence for a reduction in risk of DN with optimal blood glucose control achieved using multiple insulin injections in people with type 2 diabetes, but the evidence is not as strong as that for type 1 diabetes.[34]

Lifestyle interventions (diet and exercise) are recommended as they may improve neuropathic symptoms and intra-epidermal nerve fibre density in patients with neuropathy and impaired glucose tolerance.[131][132]​​​ Treatment of other modifiable risk factors (e.g., obesity, lipids and blood pressure) may also be beneficial in patients with both type 1 and type 2 diabetes.[39] Control of these modifiable risk factors (glucose, blood pressure, and lipids) in addition to adhering to a healthy lifestyle may prevent other associated microvascular complications of diabetes (retinopathy and nephropathy).[39]​​ The American Academy of Neurology also recommends cognitive behavioural therapy and mindfulness as potential options for patients with painful DN.[66]

Proper care of the foot begins with educating the patient.[128] Minor non-infected wounds without evidence of soft-tissue or bone infection do not require antibiotic therapy. More serious problems are best handled in consultation with specialists in diabetic foot care.[92][93]

Assess patient for comorbid mood disorders, particularly depression and anxiety, and sleep disorders.[24][66][101][102]​​​[104]​​[105]​ The presence of sleep disorders or mood disorders can affect perception of pain; treatment may help reduce pain and improve quality of life.[66]

cranial neuropathies

1st line – glycaemic control and supportive measures

Back
ONGOING
|
cranial neuropathies
1st line – 

glycaemic control and supportive measures

There is no specific treatment, although gradual recovery typically occurs.

There is some evidence for a reduction in risk of DN with optimal blood glucose control achieved using multiple insulin injections in people with type 2 diabetes, but the evidence is not as strong as that for type 1 diabetes.[34]

Lifestyle interventions (diet and exercise) are recommended as they may improve neuropathic symptoms and intra-epidermal nerve fibre density in patients with neuropathy and impaired glucose tolerance.[131][132]​​​ Treatment of other modifiable risk factors (e.g., obesity, lipids and blood pressure) may also be beneficial in patients with both type 1 and type 2 diabetes.[39]​ Control of these modifiable risk factors (glucose, blood pressure, and lipids) in addition to adhering to a healthy lifestyle may prevent other associated microvascular complications of diabetes (retinopathy and nephropathy).​[39]

Proper care of the foot begins with educating the patient.[128] Minor non-infected wounds without evidence of soft-tissue or bone infection do not require antibiotic therapy. More serious problems are best handled in consultation with specialists in diabetic foot care.[92][93]

Assess patient for comorbid mood disorders, particularly depression and anxiety, and sleep disorders.[24][66][101][102]​​​[104]​​[105]​ The presence of sleep disorders or mood disorders can affect perception of pain; treatment may help reduce pain and improve quality of life.[66] 

limb or truncal mononeuropathies

1st line – glycaemic control and supportive measures

Back
ONGOING
|
limb or truncal mononeuropathies
1st line – 

glycaemic control and supportive measures

There is no specific treatment for abrupt limb mononeuropathies, though some have advocated immunomodulatory therapy when there is multi-nerve involvement.

Once structural abnormalities have been ruled out, treatment for diabetic truncal mononeuropathy consists of pain management. Improvement is generally gradual.

There is some evidence for a reduction in risk of DN with optimal blood glucose control achieved using multiple insulin injections in people with type 2 diabetes, but the evidence is not as strong as that for type 1 diabetes.[34]

Lifestyle interventions (diet and exercise) are recommended as they may improve neuropathic symptoms and intra-epidermal nerve fibre density in patients with neuropathy and impaired glucose tolerance.[131][132]​​​ Treatment of other modifiable risk factors (e.g., obesity, lipids and blood pressure) may also be beneficial in patients with both type 1 and type 2 diabetes.[39] ​Control of these modifiable risk factors (glucose, blood pressure, and lipids) in addition to adhering to a healthy lifestyle may prevent other associated microvascular complications of diabetes (retinopathy and nephropathy).​[39]

Proper care of the foot begins with educating the patient.[128] Minor non-infected wounds without evidence of soft-tissue or bone infection do not require antibiotic therapy. More serious problems are best handled in consultation with specialists in diabetic foot care.[92][93]

Assess patient for comorbid mood disorders, particularly depression and anxiety, and sleep disorders.[24][66][101][102]​​​[104]​​[105]​ The presence of sleep disorders or mood disorders can affect perception of pain; treatment may help reduce pain and improve quality of life.[66] 

diabetic amyotrophy

1st line – glycaemic control and supportive measures

Back
ONGOING
|
diabetic amyotrophy
1st line – 

glycaemic control and supportive measures

Typically, no treatment is given for diabetic amyotrophy, other than improving glycaemic control.

However, patients with inflammatory changes on biopsy may respond to immunomodulation.[173]

There is some evidence for a reduction in risk of DN with optimal blood glucose control achieved using multiple insulin injections in people with type 2 diabetes, but the evidence is not as strong as that for type 1 diabetes.[34]

Lifestyle interventions (diet and exercise) are recommended as they may improve neuropathic symptoms and intra-epidermal nerve fibre density in patients with neuropathy and impaired glucose tolerance.[131][132]​​​ Treatment of other modifiable risk factors (e.g., obesity, lipids and blood pressure) may also be beneficial in patients with both type 1 and type 2 diabetes.[39]​ Control of these modifiable risk factors (glucose, blood pressure, and lipids) in addition to adhering to a healthy lifestyle may prevent other associated microvascular complications of diabetes (retinopathy and nephropathy).​[39]

Proper care of the foot begins with educating the patient.[128] Minor non-infected wounds without evidence of soft-tissue or bone infection do not require antibiotic therapy. More serious problems are best handled in consultation with specialists in diabetic foot care.[92][93]

Assess patient for comorbid mood disorders, particularly depression and anxiety, and sleep disorders.[24][66][101][102]​​​[104]​​[105]​ The presence of sleep disorders or mood disorders can affect perception of pain; treatment may help reduce pain and improve quality of life.[66] 

diabetic autonomic neuropathy

1st line – simple non-pharmacological measures plus midodrine plus glycaemic control and supportive measures

Back
ONGOING
|
diabetic autonomic neuropathy
|
orthostatic hypotension
1st line – 

simple non-pharmacological measures plus midodrine plus glycaemic control and supportive measures

Simple measures include avoiding sudden changes in body posture to the head-up position; avoiding medications that aggravate hypotension; eating small, frequent meals; avoiding a low-salt diet; adequate fluid intake; avoiding activities that involve straining.

Elevating the head of the bed 45 cm (18 inches) at night improved symptoms in a small series of patients with orthostatic hypotension from various causes.[176]

Case reports suggest that a compressive garment over the legs and abdomen may be of benefit.[177][178][179][180]

An inflatable abdominal band was effective in a study of 6 patients with orthostatic hypotension.[181]

Using a low portable chair as needed for symptoms was found to be effective in one study.[182]

Several physical counter-manoeuvres, such as leg crossing, squatting, and muscle pumping, can help maintain BP.[183]

Midodrine is the only agent approved for the treatment of orthostatic hypotension in some countries. Several double-blind, placebo-controlled studies have documented its efficacy in the treatment of orthostatic hypotension.[193][194][195]​ The main adverse effects are piloerection, pruritus, paraesthesias, urinary retention, and supine hypertension.

There is some evidence for a reduction in risk of DN with optimal blood glucose control achieved using multiple insulin injections in people with type 2 diabetes, but the evidence is not as strong as that for type 1 diabetes.[34]

Lifestyle interventions (diet and exercise) are recommended as they may improve neuropathic symptoms and intra-epidermal nerve fibre density in patients with neuropathy and impaired glucose tolerance.[131][132]​​​ Treatment of other modifiable risk factors (e.g., obesity, lipids and blood pressure) may also be beneficial in patients with both type 1 and type 2 diabetes.[39]​ Control of these modifiable risk factors (glucose, blood pressure, and lipids) in addition to adhering to a healthy lifestyle may prevent other associated microvascular complications of diabetes (retinopathy and nephropathy).​ [39]

Proper care of the foot begins with educating the patient.[128] Minor non-infected wounds without evidence of soft-tissue or bone infection do not require antibiotic therapy. More serious problems are best handled in consultation with specialists in diabetic foot care.[92][93]

Assess patient for comorbid mood disorders, particularly depression and anxiety, and sleep disorders.[24][66][101][102]​​​[104]​​[105]​ The presence of sleep disorders or mood disorders can affect perception of pain; treatment may help reduce pain and improve quality of life.[66] 

Primary options

midodrine: 2.5 to 10 mg orally three times daily

2nd line – simple non-pharmacological measures plus mixed alpha-adrenoreceptor agonist plus glycaemic control and supportive measures

Back
ONGOING
|
diabetic autonomic neuropathy
|
orthostatic hypotension
2nd line – 

simple non-pharmacological measures plus mixed alpha-adrenoreceptor agonist plus glycaemic control and supportive measures

Simple measures include avoiding sudden changes in body posture to the head-up position; avoiding medications that aggravate hypotension; eating small, frequent meals; avoiding a low-salt diet; adequate fluid intake; avoiding activities that involve straining.

Elevating the head of the bed 45 cm (18 inches) at night improved symptoms in a small series of patients with orthostatic hypotension from various causes.[176]

Case reports suggest that a compressive garment over the legs and abdomen may be of benefit.[177][178][179][180]

An inflatable abdominal band was effective in a study of 6 patients with orthostatic hypotension.[181]

Using a low portable chair as needed for symptoms was found to be effective in one study.[182]

Several physical counter-manoeuvres, such as leg crossing, squatting, and muscle pumping, can help maintain BP.[183]

Mixed alpha-adrenoreceptor agonists include pseudoephedrine.[196] Pseudoephedrine-containing medicines are associated with a risk of posterior reversible encephalopathy syndrome (PRES) and reversible cerebral vasoconstriction syndrome (RCVS). These are rare conditions with potentially serious and life-threatening complications. Pseudoephedrine-containing medicines should not be used in patients with severe or uncontrolled hypertension, or those with severe acute or chronic renal disease or failure.[198]

Severe hypertension is an important adverse effect of all sympathomimetic agents. Other adverse effects, which may limit their use, are tremulousness, irritability, insomnia, tachycardia, reduced appetite, and, in men, urinary retention.[197]

There is some evidence for a reduction in risk of DN with optimal blood glucose control achieved using multiple insulin injections in people with type 2 diabetes, but the evidence is not as strong as that for type 1 diabetes.[34]

Lifestyle interventions (diet and exercise) are recommended as they may improve neuropathic symptoms and intra-epidermal nerve fibre density in patients with neuropathy and impaired glucose tolerance.[131][132]​​​ Treatment of other modifiable risk factors (e.g., obesity, lipids and blood pressure) may also be beneficial in patients with both type 1 and type 2 diabetes.[39]​ Control of these modifiable risk factors (glucose, blood pressure, and lipids) in addition to adhering to a healthy lifestyle may prevent other associated microvascular complications of diabetes (retinopathy and nephropathy).[39]

Proper care of the foot begins with educating the patient.[128] Minor non-infected wounds without evidence of soft-tissue or bone infection do not require antibiotic therapy. More serious problems are best handled in consultation with specialists in diabetic foot care.[92][93]

Assess patient for comorbid mood disorders, particularly depression and anxiety, and sleep disorders.[24][66][101][102]​​​[104]​​[105]​ The presence of sleep disorders or mood disorders can affect perception of pain; treatment may help reduce pain and improve quality of life.[66] 

Primary options

pseudoephedrine: 30-60 mg orally three times daily

3rd line – simple non-pharmacological measures plus mineralocorticoid plus glycaemic control and supportive measures

Back
ONGOING
|
diabetic autonomic neuropathy
|
orthostatic hypotension
3rd line – 

simple non-pharmacological measures plus mineralocorticoid plus glycaemic control and supportive measures

Simple measures include avoiding sudden changes in body posture to the head-up position; avoiding medications that aggravate hypotension; eating small, frequent meals; avoiding a low-salt diet; adequate fluid intake; avoiding activities that involve straining.

Elevating the head of the bed 45 cm (18 inches) at night improved symptoms in a small series of patients with orthostatic hypotension from various causes.[176]

Case reports suggest that a compressive garment over the legs and abdomen may be of benefit.[177][178][179][180]

An inflatable abdominal band was effective in a study of 6 patients with orthostatic hypotension.[181]

Using a low portable chair as needed for symptoms was found to be effective in one study.[182]

Several physical counter-manoeuvres, such as leg crossing, squatting, and muscle pumping, can help maintain BP.[183]

The effects of fludrocortisone are not immediate, but occur over a 1- to 2-week period.

Supine hypertension, hypokalaemia, and hypomagnesaemia may occur. Caution must be used, particularly in patients with congestive heart failure, to avoid fluid overload.[189][190]

There is some evidence for a reduction in risk of DN with optimal blood glucose control achieved using multiple insulin injections in people with type 2 diabetes, but the evidence is not as strong as that for type 1 diabetes.

Lifestyle interventions (diet and exercise) are recommended as they may improve neuropathic symptoms and intra-epidermal nerve fibre density in patients with neuropathy and impaired glucose tolerance.[131][132]​​​ Treatment of other modifiable risk factors (e.g., obesity, lipids and blood pressure) may also be beneficial in patients with both type 1 and type 2 diabetes.[39]​ Control of these modifiable risk factors (glucose, blood pressure, and lipids) in addition to adhering to a healthy lifestyle may prevent other associated microvascular complications of diabetes (retinopathy and nephropathy).[39]​

Proper care of the foot begins with educating the patient.[128] Minor non-infected wounds without evidence of soft-tissue or bone infection do not require antibiotic therapy. More serious problems are best handled in consultation with specialists in diabetic foot care.[92][93]

Assess patient for comorbid mood disorders, particularly depression and anxiety, and sleep disorders.[24][66][101][102]​​​[104]​​[105]​ The presence of sleep disorders or mood disorders can affect perception of pain; treatment may help reduce pain and improve quality of life.[66] 

Primary options

fludrocortisone: 0.1 to 0.2 mg orally once daily

4th line – simple non-pharmacological measures plus other pharmacological treatments plus glycaemic control and supportive measures

Back
ONGOING
|
diabetic autonomic neuropathy
|
orthostatic hypotension
4th line – 

simple non-pharmacological measures plus other pharmacological treatments plus glycaemic control and supportive measures

Simple measures include avoiding sudden changes in body posture to the head-up position; avoiding medications that aggravate hypotension; eating small, frequent meals; avoiding a low-salt diet; adequate fluid intake; avoiding activities that involve straining.

Elevating the head of the bed 45 cm (18 inches) at night improved symptoms in a small series of patients with orthostatic hypotension from various causes.[176]

Case reports suggest that a compressive garment over the legs and abdomen may be of benefit.[177][178][179][180]

An inflatable abdominal band was effective in a study of 6 patients with orthostatic hypotension.[181]

Using a low portable chair as needed for symptoms was found to be effective in one study.[182]

Several physical counter-manoeuvres, such as leg crossing, squatting, and muscle pumping, can help maintain BP.[183]

Erythropoietin (epoetin alfa) improves standing BP in patients with orthostatic hypotension.[67]

Octreotide may attenuate the postprandial BP fall and reduce orthostatic hypotension in patients with autonomic failure. A long-acting intramuscular depot may also be used.

There is some evidence for a reduction in risk of DN with optimal blood glucose control achieved using multiple insulin injections in people with type 2 diabetes, but the evidence is not as strong as that for type 1 diabetes.[34]

Lifestyle interventions (diet and exercise) are recommended as they may improve neuropathic symptoms and intra-epidermal nerve fibre density in patients with neuropathy and impaired glucose tolerance.[131][132]​​​ Treatment of other modifiable risk factors (e.g., obesity, lipids and blood pressure) may also be beneficial in patients with both type 1 and type 2 diabetes.[39]​ Control of these modifiable risk factors (glucose, blood pressure, and lipids) in addition to adhering to a healthy lifestyle may prevent other associated microvascular complications of diabetes (retinopathy and nephropathy).​[39]

Proper care of the foot begins with educating the patient.[128] Minor non-infected wounds without evidence of soft-tissue or bone infection do not require antibiotic therapy. More serious problems are best handled in consultation with specialists in diabetic foot care.[92][93]

Assess patient for comorbid mood disorders, particularly depression and anxiety, and sleep disorders.[24][66][101][102]​​​[104]​​[105]​ The presence of sleep disorders or mood disorders can affect perception of pain; treatment may help reduce pain and improve quality of life.[66] 

Primary options

epoetin alfa: 25-75 units/kg subcutaneously three times weekly initially until haematocrit approaches normal, followed by lower maintenance dose

OR

octreotide: 25-200 micrograms/day subcutaneously given in divided doses every 8 hours; long-acting depot: 20-30 mg intramuscularly once monthly

1st line – pharmacological methods plus glycaemic control and supportive measures

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ONGOING
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diabetic autonomic neuropathy
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diabetic gastroparesis
1st line – 

pharmacological methods plus glycaemic control and supportive measures

Erythromycin increases gastric emptying in a dose-dependent manner.[205]

Metoclopramide has anti-emetic properties.[204] Possible adverse effects include extrapyramidal symptoms, such as acute dystonic reactions; drug-induced parkinsonism; akathisia; and tardive dyskinesia. Galactorrhoea, amenorrhoea, gynaecomastia, and hyperprolactinaemia may also occur.

Metoclopramide should be used for up to 5 days only in order to minimise the risk of neurological and other adverse effects.[209] Its use for the long-term treatment of gastroparesis is no longer recommended. It should be reserved for short-term use in severe cases that are unresponsive to other therapies. Adverse effects should be closely monitored.

The European Medicines Agency and the UK Medicines and Healthcare products Regulatory Agency recommend a careful risk/benefit assessment before prescribing domperidone for this off-label indication, as it is associated with a small increased risk of potentially life-threatening effects on the heart. It should be used at the lowest effective dose for the shortest possible duration and the maximum treatment duration should not usually exceed 1 week. The maximum dose in adults is 30 mg/day. Domperidone is contraindicated in patients with severe hepatic impairment or underlying cardiac disease. It should not be administered with other drugs that prolong the QT interval or inhibit CYP3A4.[213]

There have been several case reports of patients with severe diabetic gastroparesis (whose symptoms persisted despite dietary changes and the use of high-dose prokinetic agents) experiencing significant symptomatic improvement after intrapyloric botulinum toxin injection during upper gastrointestinal endoscopy.[214][215][216]

There is some evidence for a reduction in risk of DN with optimal blood glucose control achieved using multiple insulin injections in people with type 2 diabetes, but the evidence is not as strong as that for type 1 diabetes.[34]

Lifestyle interventions (diet and exercise) are recommended as they may improve neuropathic symptoms and intra-epidermal nerve fibre density in patients with neuropathy and impaired glucose tolerance.[131][132]​​​ Some lifestyle measures for diabetic gastroparesis are based on commonly accepted clinical practices. These include the use of multiple small feedings and changes in diet, such as a decrease in dietary fat and fibre.[202][203][204]​​ Treatment of other modifiable risk factors (e.g., obesity, lipids and blood pressure) may also be beneficial in patients with both type 1 and type 2 diabetes.[39]​ Control of these modifiable risk factors (glucose, blood pressure, and lipids) in addition to adhering to a healthy lifestyle may prevent other associated microvascular complications of diabetes (retinopathy and nephropathy).​[39]

Proper care of the foot begins with educating the patient.[128] Minor non-infected wounds without evidence of soft-tissue or bone infection do not require antibiotic therapy. More serious problems are best handled in consultation with specialists in diabetic foot care.[92][93]

Assess patient for comorbid mood disorders, particularly depression and anxiety, and sleep disorders.[24][66][101][102]​​​[104]​​[105]​ The presence of sleep disorders or mood disorders can affect perception of pain; treatment may help reduce pain and improve quality of life.[66] 

Primary options

erythromycin base: 250 mg orally four times daily 30 minutes before meals and at bedtime

Secondary options

metoclopramide: 5-10 mg orally three times daily for a maximum of 5 days, maximum 30 mg/day

OR

domperidone: 10 mg orally three times daily for a maximum of 7 days, maximum 30 mg/day

OR

botulinum toxin type A: consult specialist for guidance on dose

2nd line – non-pharmacological methods plus glycaemic control and supportive measures

Back
ONGOING
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diabetic autonomic neuropathy
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diabetic gastroparesis
2nd line – 

non-pharmacological methods plus glycaemic control and supportive measures

Persistent vomiting may require placement of a feeding jejunostomy to bypass an atonic stomach.[204]

Non-pharmacological methods (gastric pacing and surgery) have been used to treat diabetic gastroparesis in patients unresponsive to pharmacotherapy. However, the evidence for gastric pacing (stimulation) in the management of diabetic gastroparesis is limited and does not allow for the identification of specific patient populations or the development of well-defined clinical criteria. It is, therefore, not used routinely in clinical practice and further research is needed.[39][218]

Radical surgery, consisting of resection of a large portion of the stomach, with performance of a Roux-en-Y loop, was successful in a small series of patients.[219]

There is some evidence for a reduction in risk of DN with optimal blood glucose control achieved using multiple insulin injections in people with type 2 diabetes, but the evidence is not as strong as that for type 1 diabetes.[34]

Lifestyle interventions (diet and exercise) are recommended as they may improve neuropathic symptoms and intra-epidermal nerve fibre density in patients with neuropathy and impaired glucose tolerance.[131][132]​​​​ Some lifestyle measures for diabetic gastroparesis are based on commonly accepted clinical practices. These include the use of multiple small meals and changes in diet, such as a decrease in dietary fat and fibre.[202][203][204]​​ Treatment of other modifiable risk factors (e.g., obesity, lipids and blood pressure) may also be beneficial in patients with both type 1 and type 2 diabetes.[39]​ Control of these modifiable risk factors (glucose, blood pressure, and lipids) in addition to adhering to a healthy lifestyle may prevent other associated microvascular complications of diabetes (retinopathy and nephropathy).​[39]

Proper care of the foot begins with educating the patient.[128] Minor non-infected wounds without evidence of soft-tissue or bone infection do not require antibiotic therapy. More serious problems are best handled in consultation with specialists in diabetic foot care.[92][93]

Assess patient for comorbid mood disorders, particularly depression and anxiety, and sleep disorders.[24][66][101][102]​​​[104]​​[105]​ The presence of sleep disorders or mood disorders can affect perception of pain; treatment may help reduce pain and improve quality of life.[66] 

1st line – broad-spectrum antibiotics plus glycaemic control and supportive measures

Back
ONGOING
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diabetic autonomic neuropathy
|
diabetic diarrhoea
1st line – 

broad-spectrum antibiotics plus glycaemic control and supportive measures

Broad-spectrum antibiotics are commonly used to treat diabetic diarrhoea, either when the hydrogen breath test is positive or as an empirical trial.[99]

An early double-blind study, involving a single patient, found that diarrhoea subsided when the patient was treated with an oral antibiotic preparation, then recurred when placebo was substituted.[220]

Several different regimens have been advocated. Caution must be used because long-term use of metronidazole can lead to neuropathy.

There is some evidence for a reduction in risk of DN with optimal blood glucose control achieved using multiple insulin injections in people with type 2 diabetes, but the evidence is not as strong as that for type 1 diabetes.[34]

Lifestyle interventions (diet and exercise) are recommended as they may improve neuropathic symptoms and intra-epidermal nerve fibre density in patients with neuropathy and impaired glucose tolerance.[131][132]​​​ Treatment of other modifiable risk factors (e.g., obesity, lipids and blood pressure) may also be beneficial in patients with both type 1 and type 2 diabetes.[39]​ Control of these modifiable risk factors (glucose, blood pressure, and lipids) in addition to adhering to a healthy lifestyle may prevent other associated microvascular complications of diabetes (retinopathy and nephropathy).​[39]

Proper care of the foot begins with educating the patient.[128] Minor non-infected wounds without evidence of soft-tissue or bone infection do not require antibiotic therapy. More serious problems are best handled in consultation with specialists in diabetic foot care.[92][93]

Assess patient for comorbid mood disorders, particularly depression and anxiety, and sleep disorders.[24][66][101][102]​​​[104]​​[105]​ The presence of sleep disorders or mood disorders can affect perception of pain; treatment may help reduce pain and improve quality of life.[66] 

Primary options

metronidazole: 500 mg orally every 6 hours for 3 weeks; or 750 mg orally every 8 hours for 3 weeks

OR

ampicillin: 250 mg orally every 6-8 hours for 14 days

OR

tetracycline: 250 mg orally every 6-8 hours for 14 days

OR

amoxicillin/clavulanate: 875 mg orally every 12 hours for 14 days

More

2nd line – colestyramine plus glycaemic control and supportive measures

Back
ONGOING
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diabetic autonomic neuropathy
|
diabetic diarrhoea
2nd line – 

colestyramine plus glycaemic control and supportive measures

Colestyramine can be used in an attempt to chelate bile salts if the hydrogen breath test is normal, or if patients fail an empirical trial of broad-spectrum antibiotics.

There is some evidence for a reduction in risk of DN with optimal blood glucose control achieved using multiple insulin injections in people with type 2 diabetes, but the evidence is not as strong as that for type 1 diabetes.[34]

Lifestyle interventions (diet and exercise) are recommended as they may improve neuropathic symptoms and intra-epidermal nerve fibre density in patients with neuropathy and impaired glucose tolerance.[131][132]​​​ Treatment of other modifiable risk factors (e.g., obesity, lipids and blood pressure) may also be beneficial in patients with both type 1 and type 2 diabetes.[39] ​Control of these modifiable risk factors (glucose, blood pressure, and lipids) in addition to adhering to a healthy lifestyle may prevent other associated microvascular complications of diabetes (retinopathy and nephropathy).​[39]

Proper care of the foot begins with educating the patient.[128] Minor non-infected wounds without evidence of soft-tissue or bone infection do not require antibiotic therapy. More serious problems are best handled in consultation with specialists in diabetic foot care.[92][93]

Assess patient for comorbid mood disorders, particularly depression and anxiety, and sleep disorders.[24][66][101][102]​​​[104]​​[105]​ The presence of sleep disorders or mood disorders can affect perception of pain; treatment may help reduce pain and improve quality of life.[66]

Primary options

colestyramine: 2-4 g orally two to four times daily

3rd line – octreotide plus glycaemic control and supportive measures

Back
ONGOING
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diabetic autonomic neuropathy
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diabetic diarrhoea
3rd line – 

octreotide plus glycaemic control and supportive measures

Octreotide was effective in a case report of a single patient with diabetic diarrhoea.[221]

In healthy volunteers, octreotide improved gastric, small bowel, and colonic transit, and colonic motility and tone.[222] Octreotide may be considered for the management of diabetic diarrhoea when other approaches have failed.

There is some evidence for a reduction in risk of DN with optimal blood glucose control achieved using multiple insulin injections in people with type 2 diabetes, but the evidence is not as strong as that for type 1 diabetes.[34]

Lifestyle interventions (diet and exercise) are recommended as they may improve neuropathic symptoms and intra-epidermal nerve fibre density in patients with neuropathy and impaired glucose tolerance.[131][132]​​​ Treatment of other modifiable risk factors (e.g., obesity, lipids and blood pressure) may also be beneficial in patients with both type 1 and type 2 diabetes.[39]​ Control of these modifiable risk factors (glucose, blood pressure, and lipids) in addition to adhering to a healthy lifestyle may prevent other associated microvascular complications of diabetes (retinopathy and nephropathy).[39]

Proper care of the foot begins with educating the patient.[128] Minor non-infected wounds without evidence of soft-tissue or bone infection do not require antibiotic therapy. More serious problems are best handled in consultation with specialists in diabetic foot care.[92][93]

Assess patient for comorbid mood disorders, particularly depression and anxiety, and sleep disorders.[24][66][101][102]​​​[104]​​[105]​ The presence of sleep disorders or mood disorders can affect perception of pain; treatment may help reduce pain and improve quality of life.[66] 

Primary options

octreotide: 75-200 micrograms subcutaneously two to three times daily; long-acting depot: 20-30 mg intramuscularly once monthly

1st line – bethanechol plus glycaemic control and supportive measures

Back
ONGOING
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diabetic autonomic neuropathy
|
bladder dysfunction
1st line – 

bethanechol plus glycaemic control and supportive measures

Bethanechol, a parasympathomimetic agent, may be helpful for people with symptoms of bladder dysfunction.

There is some evidence for a reduction in risk of DN with optimal blood glucose control achieved using multiple insulin injections in people with type 2 diabetes, but the evidence is not as strong as that for type 1 diabetes.[34]

Lifestyle interventions (diet and exercise) are recommended as they may improve neuropathic symptoms and intra-epidermal nerve fibre density in patients with neuropathy and impaired glucose tolerance.[131][132]​​​ Treatment of other modifiable risk factors (e.g., obesity, lipids and blood pressure) may also be beneficial in patients with both type 1 and type 2 diabetes.[39]​ Control of these modifiable risk factors (glucose, blood pressure, and lipids) in addition to adhering to a healthy lifestyle may prevent other associated microvascular complications of diabetes (retinopathy and nephropathy).​[39]

Proper care of the foot begins with educating the patient.[128] Minor non-infected wounds without evidence of soft-tissue or bone infection do not require antibiotic therapy. More serious problems are best handled in consultation with specialists in diabetic foot care.[92][93]

Assess patient for comorbid mood disorders, particularly depression and anxiety, and sleep disorders.[24][66][101][102]​​​[104]​​[105]​ The presence of sleep disorders or mood disorders can affect perception of pain; treatment may help reduce pain and improve quality of life.[66] 

Primary options

bethanechol: 10-30 mg orally three times daily

Consider – bladder hygiene techniques

Back
ONGOING
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diabetic autonomic neuropathy
|
bladder dysfunction
Consider – 

bladder hygiene techniques

Additional treatment recommended for SOME patients in selected patient group

Bladder training, such as scheduled voiding, may be used particularly for urge incontinence.

The Crede manoeuvre may also be used. This method helps to empty the bladder if it is weak and flaccid. The patient pushes with a hand down on the abdomen from the umbilicus towards the bladder in a smooth, even manner.[99]

1st line – pharmacotherapy plus glycaemic control and supportive measures

Back
ONGOING
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diabetic autonomic neuropathy
|
erectile dysfunction
1st line – 

pharmacotherapy plus glycaemic control and supportive measures

The first-line therapy for erectile dysfunction (ED) is a phosphodiesterase-5 (PDE-5) inhibitor.

PDE-5 inhibitors revolutionised the management of ED and are efficient and safe. Both sildenafil and tadalafil significantly increase erectile function and are generally well tolerated.[224][225]​ However, adverse effects may occur, with headache and flushing the most commonly reported. Flu-like syndromes, dyspepsia, myalgias, abnormal vision, and back pain may occur less frequently. Dose may need to be adjusted if the patient is on other drugs; check drug-drug interactions before prescribing.

The second-line option for treatment of ED is intracavernosal injection with papaverine, an opioid alkaloid, or alprostadil, a synthetic analogue of prostaglandin E1. The success rate of intracavernosal injections is high, with nearly 90% of patients achieving erection.[226][227]​ Direct injections can be into the corpus cavernosum or by urethral suppository.

A topically applied cream formulation of alprostadil is a third-line option for the treatment of diabetic ED in Europe and other countries including Canada. It is not available in the US. Alprostadil is delivered with a permeation enhancer to facilitate local absorption. Other benefits include avoidance of a contraindication with organic nitrates, fast onset of action, and minimal drug-drug interactions.[228]

There is some evidence for a reduction in risk of DN with optimal blood glucose control achieved using multiple insulin injections in people with type 2 diabetes, but the evidence is not as strong as that for type 1 diabetes.[34]

Lifestyle interventions (diet and exercise) are recommended as they may improve neuropathic symptoms and intra-epidermal nerve fibre density in patients with neuropathy and impaired glucose tolerance.[131][132]​​​ Treatment of other modifiable risk factors (e.g. obesity, lipids and blood pressure) may also be beneficial in patients with both type 1 and type 2 diabetes.[39]​ Control of these modifiable risk factors (glucose, blood pressure, and lipids) in addition to adhering to a healthy lifestyle may prevent other associated microvascular complications of diabetes (retinopathy and nephropathy).​[39]

Proper care of the foot begins with educating the patient.[128] Minor non-infected wounds without evidence of soft-tissue or bone infection do not require antibiotic therapy. More serious problems are best handled in consultation with specialists in diabetic foot care.[92][93]

Assess patient for comorbid mood disorders, particularly depression and anxiety, and sleep disorders.[24][66][101][102]​​​[104]​​[105]​ The presence of sleep disorders or mood disorders can affect perception of pain; treatment may help reduce pain and improve quality of life.[66] 

Primary options

sildenafil: 25-100 mg orally taken 1 hour before anticipated sexual activity

OR

tadalafil: 5-20 mg orally taken 45 minutes before anticipated sexual activity

OR

vardenafil: 5-20 mg orally taken 45 minutes before anticipated sexual activity

OR

avanafil: 50-200 mg orally taken 15-30 minutes before anticipated sexual activity

Secondary options

papaverine: consult specialist for guidance on dose

OR

alprostadil intracavernous: 10-20 micrograms when required, titrate dose according to response, maximum 60 micrograms/dose, maximum 3 doses/week, with at least 24 hours between each dose

OR

alprostadil intraurethral: 125-250 micrograms when required, increase dose according to response, doses of up to 1000 micrograms/day have been reported

Tertiary options

alprostadil topical: consult specialist for guidance on dose

Consider – non-pharmacological methods

Back
ONGOING
|
diabetic autonomic neuropathy
|
erectile dysfunction
Consider – 

non-pharmacological methods

Additional treatment recommended for SOME patients in selected patient group

Several case reports have described the use of vacuum devices, rigid penile implants, and inflatable prostheses for the treatment of ED.[227][229]

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