How to manage a patient with orthostatic hypotension, polyuria, low cortisol (adrenocorticotropic hormone) level, hyponatremia, and a spinal cord injury?

From the Guidelines

Management of a patient with orthostatic hypotension, polyuria, low cortisol, hyponatremia, and spinal cord injury requires a comprehensive approach targeting the underlying adrenal insufficiency, with the most recent and highest quality study guiding the treatment approach 1.

Key Components of Management

• Addressing cortisol deficiency with hydrocortisone replacement, typically starting with 15-20 mg in the morning and 5-10 mg in the afternoon, as this regimen allows for the recreation of the diurnal rhythm of cortisol 1.
• Managing hyponatremia by restricting free water intake to 1-1.5 liters daily and administering 3% hypertonic saline if sodium levels are severely low (<125 mEq/L).
• Initiating midodrine 2.5-10 mg three times daily (last dose before 6 PM to avoid supine hypertension) and fludrocortisone 0.1-0.2 mg daily to enhance sodium retention and increase blood volume, based on the guidelines for managing orthostatic hypotension 1.
• Implementing non-pharmacological measures such as encouraging salt intake of 6-10 g daily, using compression stockings, elevating the head of the bed 30 degrees at night, and gradual position changes.
• Considering desmopressin 0.1-0.2 mg twice daily for polyuria if diabetes insipidus is confirmed.

Monitoring and Adjustments

• Regular monitoring of electrolytes, blood pressure (both supine and standing), and fluid balance is essential to adjust the treatment plan as needed.
• Education on stress dosing for sick days, use of emergency injectables, and when to seek medical attention for impending adrenal crisis, along with a medical alert bracelet or necklace for adrenal insufficiency, is crucial for patient safety 1.

Prioritizing Morbidity, Mortality, and Quality of Life

The approach outlined prioritizes reducing morbidity and mortality by addressing the underlying causes of the patient's symptoms, while also improving quality of life through comprehensive management of orthostatic hypotension, polyuria, and hormonal deficiencies. This is in line with the most recent guidelines and evidence-based practices 1.

From the FDA Drug Label

Midodrine hydrochloride tablets are indicated for the treatment of symptomatic orthostatic hypotension (OH) The indication is based on midodrine's effect on increases in 1-minute standing systolic blood pressure, a surrogate marker considered likely to correspond to a clinical benefit. Midodrine should be used with caution in patients with renal impairment, with a starting dose of 2.5 mg Midodrine use has not been studied in patients with hepatic impairment. Midodrine should be used with caution in patients with hepatic impairment, as the liver has a role in the metabolism of midodrine Patients who experience any signs or symptoms suggesting bradycardia (pulse slowing, increased dizziness, syncope, cardiac awareness) should be advised to discontinue midodrine and should be re-evaluated.

Management of patient with orthostatic hypotension and polyuria, low cortisol level, and hyponatremia and spinal cord injury

• Midodrine can be used to manage orthostatic hypotension, but its use should be cautious in patients with renal impairment, hepatic impairment, and those taking certain medications.
• The patient's renal and hepatic function should be assessed prior to initiating therapy with midodrine.
• The patient should be monitored for signs of supine hypertension, bradycardia, and other adverse effects.
• The dose of midodrine should be adjusted according to the patient's response and tolerance.
• Other treatments for polyuria, low cortisol level, and hyponatremia should be considered, but the FDA drug label for midodrine does not provide direct information on managing these conditions.
• The patient's condition is complex and requires careful management, but the information provided in the drug label for midodrine is limited to its use in treating orthostatic hypotension 2, 2.

From the Research

Management of Orthostatic Hypotension

• Orthostatic hypotension (OH) occurs when mechanisms for the regulation of orthostatic blood pressure control fail, and it is common in patients with spinal cord injuries (SCIs) 3.
• The treatment of OH is imperfect, but the practical goal is to improve standing blood pressure to minimize symptoms and improve standing time without excessive supine hypertension 4.
• A combination of fludrocortisone, a pressor agent (midodrine or droxidopa), and procedures to improve orthostatic defenses, such as water bolus treatment and physical countermaneuvers, can be used to manage OH 4.

Management of Polyuria and Low Cortisol Level

• There is no direct evidence in the provided studies on the management of polyuria and low cortisol level in patients with OH and SCI.
• However, it is essential to address these conditions as they can exacerbate OH and affect the overall management of the patient.

Management of Hyponatremia

• There is no direct evidence in the provided studies on the management of hyponatremia in patients with OH and SCI.
• However, it is crucial to correct hyponatremia as it can worsen OH and increase the risk of falls and syncope.

Management of Spinal Cord Injury

• The site and extent of a spinal cord injury determine the degree of autonomic involvement in cardiovascular dysfunction after the injury 3.
• A systematic review of the management of OH after SCI found that midodrine was effective in managing OH, and functional electrical stimulation was one of the only nonpharmacologic interventions with some evidence to support its utility 5.

Overall Management

• A multidisciplinary, patient-centered approach is necessary to manage OH, polyuria, low cortisol level, hyponatremia, and SCI 6.
• A stepwise approach to evaluate and treat patients with OH, including behavioral, nonpharmacologic, and pharmacologic strategies, can be effective in managing these conditions 7.