I have a problem that I never see addressed. I’ve had type 1 diabetes for 36 years and been diagnosed as having diabetic diarrhea. Numerous tests have ruled out all other gastrointestinal problems. Is there any treatment for this problem?  

Name Withheld

Janis McWilliams, RN, MSN, CDE, BC-ADM, responds: People with diabetes may, of course, develop diarrhea for a variety of reasons, just like anyone else. Diarrhea is a symptom of many diseases such as viral or bacterial infections, celiac disease, irritable bowel syndrome, and Crohn’s disease. It is a side effect of some medications, such as metformin, and some sugar-free sweeteners can cause diarrhea in some people.

However, diarrhea can also be a symptom of a type of autonomic neuropathy. This is what is known as diabetic diarrhea. Although this condition is not uncommon, the diagnosis is usually made only after a detailed history and diagnostic tests reveal no other cause for the diarrhea. 

Unlike the more widely known peripheral sensory neuropathy, which affects the hands and feet, autonomic neuropathy damages the nerves that control involuntary activities of the body. More commonly known types of autonomic neuropathy include erectile dysfunction and orthostatic (or postural) hypotension, the feeling of light-headedness or dizziness you get from standing after lying or sitting down.

Diabetic diarrhea occurs usually at night, is watery and painless, and can be associated with fecal incontinence. Bouts of diarrhea can be episodic, along with intermittently normal bowel habits or even alternating with periods of constipation.

The treatment for diabetic diarrhea is individualized, but it generally starts with antidiarrheal agents such as Lomotil (a combination of diphenoxylate and atropine) or Imodium (loperamide). High-fiber foods or bulk-forming laxatives such as Metamucil may help decrease the symptoms. As with all neuropathies, good glucose control is important in controlling the symptoms.

Your doctor may order antispasmodic medicines to decrease the frequency of bowel movements. If bacterial overgrowth in the intestines is thought to be present, antibiotics may be ordered. Medications like clonidine or octreotide, which have other primary uses but have been shown to help diarrhea, can be used in more advanced cases that do not respond to other treatments. Although your primary care doctor or endocrinologist can initiate treatment for diabetic diarrhea, a referral to a gastroenterologist may be indicated when standard therapies are ineffective.