Interactive diabetes case 20: A 76-year-old patient with longstanding type 2 diabetes, orthostatic hypotension, and recurrent syncope

Case — A 76-year-old man with a 27-year history of type 2 diabetes is referred to you because of orthostatic hypotension and recurrent syncope. For the last six months, the patient has had increasingly frequent episodes of lightheadedness (usually related to rising from a lying or a sitting position), instability on his feet, and profound weakness occurring at various times of day and night. In the last three months, he has fallen one to two times a week on standing up. On at least four occasions, he lost consciousness. On one occasion, he struck his head on a toilet seat, with a laceration that required multiple sutures.

He has been in the emergency department of his community hospital five times and admitted to the hospital twice. On each occasion, the blood glucose level (obtained by the patient's wife, the emergency medical technician, or the emergency department laboratory) was over 100 mg/dL. Each time, an acute myocardial infarction was ruled out, and the patient was treated with volume repletion, although neither volume depletion nor a cause of volume loss was specifically identified.

During the second admission, a diagnosis of adrenocortical insufficiency was considered. A cosyntropin stimulation test was performed, and the patient was discharged on prednisone 5 mg every morning. This did not alleviate his symptoms. The plasma cortisol level one hour after cosyntropin 250 micrograms intravenously (IV) was subsequently reported as normal at 24 micrograms/dL (662 nmol/L). The glucocorticoid was stopped after several weeks. The patient has been confined to home by his symptoms, and his wife and son are concerned that he will suffer serious injury in a fall.

The patient has had type 2 diabetes for 27 years. His metabolic control had never been optimal, with glycated hemoglobin (A1C) values in the 8 to 9 percent range. He has refused to take insulin. His most recent A1C is 8.2 percent. In recent years, he has developed background diabetic retinopathy, distal sensory neuropathy, microalbuminuria, and hypertension.

The patient's medications are metformin 1000 mg twice a day, glipizide 10 mg before breakfast and supper, lisinopril 10 mg every morning, hydrochlorothiazide 25 mg every morning, simvastatin 40 mg every evening, aspirin 81 mg a day, alfuzosin 10 mg every morning, a multivitamin, and calcium 600 mg with vitamin D 400 international units twice a day.

The patient comes to your office in a wheelchair accompanied by his wife and son. On physical examination, the blood pressure is 150/80 mmHg right arm supine and 105/69 mmHg right arm upright, with the patient complaining of lightheadedness after standing up. The values are similar in the left arm. Pupils are equal, round, and reactive to light and accommodation. The heart rate is 88 bpm regular supine and does not rise with standing. The chest and heart examinations are within normal limits. He has evidence of distal sensory neuropathy.

Review of the outside medical records brought by the patient reveals that the most recent values, obtained three weeks earlier, are as follows: blood urea nitrogen (BUN) 29 mg/dL (10.4 mmol/L), creatinine 1.3 mg/dL (114.9 micromol/L), potassium 3.9 mEq/L, A1C 8.5 percent, urine microalbumin/creatinine ratio 329 micrograms/mg (reference <30).

You advise the patient to arise slowly from supine or seated positions (especially on arising in the morning), to have a night light in the bedroom, and to raise the head of the bed by approximately 4 inches (10 cm). You request visits from the Visiting Nurse Association to monitor blood pressure readings at home lying and standing. You also order home physical therapy to assess safety in the home and to improve the patient's ability to perform activities of daily living. (See "Treatment of orthostatic and postprandial hypotension".)

What else do you recommend for treatment of the patient's symptomatic orthostatic hypotension?

●Stop alfuzosin and hydrochlorothiazide. (See "Interactive diabetes case 20: A 76-year-old patient with longstanding type 2 diabetes, orthostatic hypotension, and recurrent syncope – A1".)

●Fludrocortisone 0.1 mg daily and high salt intake. (See "Interactive diabetes case 20: A 76-year-old patient with longstanding type 2 diabetes, orthostatic hypotension, and recurrent syncope – A2".)

●Midodrine 10 mg by mouth three times daily. (See "Interactive diabetes case 20: A 76-year-old patient with longstanding type 2 diabetes, orthostatic hypotension, and recurrent syncope – A3".)

●Clonidine 0.1 mg by mouth daily. (See "Interactive diabetes case 20: A 76-year-old patient with longstanding type 2 diabetes, orthostatic hypotension, and recurrent syncope – A4".)