Orthostatic Hypotension/Autonomic Dysfunction

Orthostatic hypotension criteria

Symptoms occurring when upright or upon standing

Lifestyle contributors and functional status

Daily fluid intake (types and amounts)

Alcohol intake

Level of physical activity

Need for assisted walking devices

Functional limitations

Injuries sustained (falls)

Alleviating factors

Aggravating factors

Screen for additional symptoms of generalized autonomic dysfunction indicative of neurogenic OH

Dry mouth, dry eyes, blurry vision, light sensitivity

Reflux, dysphagia, early satiety, bloating, post-prandial vomiting and/or dizziness

Constipation/diarrhea/fecal incontinence

Urinary urgency/frequency/retention/nocturia/incontinence

Impaired libido, erectile dysfunction, vaginal dryness, difficulty reaching orgasm

Decreased or excessive sweating

Numbness/tingling/burning of distal extremities

Screen for non-neurogenic causes and conditions associated with orthostatic hypotension

Screen for neurogenic causes and conditions associated with orthostatic hypotension

Diagnostic evaluation

EKG

Transthoracic echocardiogram

Holter monitor/loop recorder

Ambulatory blood pressure monitoring

Tilt table study

Plasma norepinephrine levels (check supine and standing)

Skin punch biopsy (evaluation for small fiber neuropathy)

Quantitative sudomotor axon reflex test (QSART- evaluation for small fiber neuropathy and post-ganglionic sudomotor dysfunction)

Other diagnostics

Conservative measures for OH tried

Regular physical activity (maintenance of vascular tone)

Use of constrictive garments (abdominal binder, waist high compression stockings)

Increase salt intake to 6-9 grams daily (if no contraindications)

Frequent small meals and avoidance of foods rich in carbohydrates (for post-prandial hypotension)

Physical counter maneuvers: legs crossing with muscle tensing, buttock clenching, gripping hands together tightly

Pharmacologic treatment for OH tried

Midodrine (1st line treatment for neurogenic and non-neurogenic OH) - may result in supine hypertension, should not be taken less than 3 hours from bedtime

Droxidopa (1st line treatment for neurogenic OH) – supine hypertension less frequently encountered

Fludrocortisone - may result in supine hypertension, should not be taken less than 3 hours from bedtime

Atomoxetine – used off label, may result in supine hypertension

Pyridostigmine - used off label, modest pressor effect when combined with midodrine or atomoxetine, does not cause supine hypertension

Measures and treatments for supine hypertension tried

Avoid supine positioning during the day, maintain head of bed at a minimum of 30 degrees at night

Carbohydrate-rich snack before bedtime

Medication selection: droxidopa (1st line), Atomoxetine + pyridostigmine (2nd line), fludrocortisone and Midodrine least preferred, evening dose should be taken earlier or omitted all together

Selective use of short-acting anti-hypertensives at bedtime, avoid alpha-blockers and diuretics