Diabetic neuropathy can involve significant autonomic dysfunction. When this manifests as orthostatic hypotension — a measurable drop in blood pressure on standing — it requires targeted pharmacological management that differs from general neuropathy care.

Clinical scenario

A patient with diabetes who, upon standing, experiences a fall in systolic blood pressure greater than 20 mmHg or a fall in diastolic blood pressure greater than 10 mmHg, consistent with autonomic involvement in advanced diabetic neuropathy.

Treatment approach (partial)

Management in this setting centres on sympathomimetic medication to counteract postural blood pressure instability. The complete protocol defines which agent applies to which subtype of orthostatic hypotension, the specific conditions governing its use, and the clinical considerations that determine selection — details available in the full regimen below.

References

DOI: 10.2337/dc16-2042

Advanced disease may also be associated with 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).

Midodrine, a peripheral, selective, direct a1-adrenoreceptor agonist, is an FDA-approved drug for the treatment of orthostatic hypotension.

Midodrine should be titrated gradually to efficacy.

It should be used only when patients intend to be upright or seated to minimize supine hypertension.

Recently, droxidopa was approved by the FDA for the treatment of neurogenic orthostatic hypotension but not specifically for patients with orthostatic hypotension due to diabetes.

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Treatment of Diabetic Neuropathy with Orthostatic Hypotension

References