Interactive diabetes case 20: A 76-year-old patient with longstanding type 2 diabetes, orthostatic hypotension, and recurrent syncope – A1

Answer — Correct.

It is essential to determine whether the signs and symptoms of orthostatic hypotension are caused or exacerbated by volume depletion or a medication before prescribing pharmacologic agents to treat this problem.

Volume depletion may be due to uncontrolled diabetes, a diuretic agent, or another cause. Offending medications include antihypertensive agents, tricyclic agents, some selective serotonin reuptake inhibitors, monoamine oxidase inhibitors, dopamine agonists, and alpha-receptor blockers such as those that are used for the treatment of bladder outlet obstruction. If one or more of these factors is causal or contributory, then the likelihood that any pharmacologic intervention will be successful is reduced, and the situation will be confounded.

Following cessation of alfuzosin and hydrochlorothiazide, the patient's orthostatic symptoms disappeared. At a return visit two weeks later, the blood pressure is 160/74 mmHg right arm supine and 130/70 mmHg right arm upright. The symptoms of bladder outlet obstruction are only slightly worse. The patient now says he can live with the symptoms and agrees to ongoing follow-up with his urologist.

In this patient, the symptoms of orthostatic hypotension disappeared following cessation of alfuzosin, an alpha-1 selective adrenergic antagonist, and hydrochlorothiazide. An orthostatic fall in blood pressure remains, probably due to underlying autonomic diabetic neuropathy.

What do you recommend now?

●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 – B1".)

●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 – B2".)

●No pharmacologic intervention at this time. Advise patient and family to report any recurrence of symptoms. (See "Interactive diabetes case 20: A 76-year-old patient with longstanding type 2 diabetes, orthostatic hypotension, and recurrent syncope – B3".)