Orthostatic Hypotension in Autonomic Neuropathy: Evidence-Based Management

This protocol addresses autonomic neuropathy in the specific context of orthostatic hypotension — a postural fall in blood pressure upon standing — with the clinical goal of minimising postural symptoms.

Clinical Scenario

Orthostatic hypotension is defined as a fall in systolic blood pressure of more than 20 mmHg, or diastolic blood pressure of more than 10 mmHg, upon standing — without an appropriate compensatory rise in heart rate. Advanced disease may also be associated with resting tachycardia (>100 bpm) alongside this postural blood pressure drop.

Approach to Management

Management combines nonpharmacologic strategies with pharmacologic agents — including options that carry specific FDA approval for orthostatic hypotension.

The full protocol details agent selection, sequencing, combination approaches, and additional guidance on managing accompanying supine hypertension. All of this is available via the button below.

Clinical Goal

Minimise postural symptoms rather than restore normotension.

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References

DOI: 10.2337/dc26-S012

Advanced disease may be associated with resting tachycardia (>100 bpm) and orthostatic hypotension (a fall in systolic or diastolic blood pressure by >20 mmHg or >10 mmHg, respectively, upon standing without an appropriate increase in heart rate).
Most individuals require both nonpharmacologic measures (e.g., ensuring adequate salt intake, avoiding medications that aggravate hypotension, or using compressive garments over the legs and abdomen) and pharmacologic measures.
Midodrine and droxidopa are approved by the FDA for the treatment of orthostatic hypotension.
The therapeutic goal is to minimize postural symptoms rather than to restore normotension.

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