Interactive diabetes case 20: A 76-year-old patient with longstanding type 2 diabetes, orthostatic hypotension, and recurrent syncope – A3

Answer — Incorrect.

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.

Midodrine, an alpha-1 selective adrenergic agonist, is often effective in increasing upright systolic blood pressure readings and in alleviating symptoms in patients with autonomic orthostatic hypotension [1-4]. It should not be used until volume depletion, a medication, or other causes of orthostatic hypotension have been excluded and until efforts to expand the extracellular fluid volume (ie, fludrocortisone and high salt intake) have been made.

In this patient with symptoms of bladder outlet obstruction, in whom it was necessary to stop alfuzosin (an alpha-1 selective adrenergic antagonist), the use of midodrine (an alpha-1 selective adrenergic agonist) is not appropriate.

Return to the beginning to try again. (See "Interactive diabetes case 20: A 76-year-old patient with longstanding type 2 diabetes, orthostatic hypotension, and recurrent syncope".)