Table 7

Cardiovascular autonomic dysfunction

SymptomTreatment approach
Orthostatic hypotension
  • Non-pharmacological methods should be tried in all patients.

  • Pharmacological treatment includes midodrine (first line) followed by fludrocortisone then pyridostigmine.

  • Regularly review need for pharmacological treatment as progressive loss of mobility decreases the duration of being upright/standing.

Supine hypertension
  • Elevate head of the bed by at least 30° overnight.

  • Avoid supine positions during the day where possible.

  • The last midodrine dose should be no less than 4 hours before bed.

  • A small carbohydrate-rich meal in the late evening may help.

  • Take a short-acting antihypertensive medication (eg, nifedipine/losartan) before bed.

Postprandial hypotension
  • Encourage small, low carbohydrate meals but increase the frequency of eating.

  • Time the midodrine dosing around meals.

  • Consider using acarbose and octreotide, although octreotide is only available for prescription in specialist centres for this indication.