Orthostatic hypotension

Management of orthostatic hypotension associated with diabetic autonomic neuropathy can be difficult; the aim is to minimise postural symptoms rather than restore normal blood pressure.

Orthostatic hypotension is often aggravated by drugs given to lower blood pressure or prevent angina. If severe orthostatic hypotension is not relieved after modifying drug therapy, graduated compression stockings may relieve symptoms by decreasing venous pooling. Also advise patients to increase salt and water intake (unless contraindicated due to a comorbid condition) and to exercise regularly (avoiding activities with frequent position changes).

For patients with diabetes who have continuing severe symptoms of orthostatic hypotension, consider:

Increase the dose of fludrocortisone with caution; it can cause fluid retention, supine hypertension and hypokalaemia.

The alpha agonist midodrine may be useful in resistant cases—seek expert advice.