From the Guidelines
The best approach to treat orthostatic hypotension in this 14-year-old male with ASD, ADHD, and social anxiety taking multiple medications would be to first implement non-pharmacological interventions, as recommended by the most recent guidelines 1. These interventions include:
- Ensuring adequate hydration with 2-3 liters of fluid daily
- Increasing salt intake to 6-10 grams per day (if not contraindicated)
- Wearing compression stockings
- Performing physical counter-maneuvers like leg crossing when standing
- Rising slowly from sitting or lying positions Medication adjustment should also be considered, as guanfacine and fluvoxamine can both contribute to orthostatic hypotension. Reducing the guanfacine dose from 4mg to 2-3mg daily under medical supervision may help while maintaining some therapeutic effect, as suggested by previous studies 1. If these measures are insufficient, pharmacological treatment with midodrine (starting at 2.5mg three times daily) or fludrocortisone (starting at 0.1mg daily) could be considered, though these should be used cautiously in adolescents, as noted in earlier research 1. The orthostatic hypotension is likely caused by the combined vasodilatory effects of guanfacine and fluvoxamine, which impair the normal sympathetic response to standing. Regular blood pressure monitoring in both sitting and standing positions is essential to evaluate treatment effectiveness and adjust the approach as needed. It's crucial to weigh the potential benefits of any medication against its risks, especially considering the patient's age and existing medical conditions, and to prioritize the most recent and highest quality evidence in making treatment decisions 1.
From the FDA Drug Label
Midodrine hydrochloride tablets are indicated for the treatment of symptomatic orthostatic hypotension (OH) Because midodrine hydrochloride tablets can cause marked elevation of supine blood pressure (BP>200 mmHg systolic), it should be used in patients whose lives are considerably impaired despite standard clinical care, including non-pharmacologic treatment (such as support stockings), fluid expansion, and lifestyle alterations
The best approach to treat orthostatic hypotension in this 14-year-old male with a history of ASD, ADHD, and social anxiety, who is taking fluvoxamine, guanfacine, and Vyvanse, is to consider midodrine as a potential treatment option, but only if his life is considerably impaired despite standard clinical care.
- The patient should first try non-pharmacologic treatments such as support stockings, fluid expansion, and lifestyle alterations.
- Midodrine should only be considered if these measures are not effective, due to the potential for marked elevation of supine blood pressure. 2
From the Research
Treatment Approaches for Orthostatic Hypotension
The treatment of orthostatic hypotension in a 14-year-old male with a history of Autism Spectrum Disorder (ASD), Attention Deficit Hyperactivity Disorder (ADHD), and social anxiety, who is taking fluvoxamine, guanfacine, and Vyvanse, involves a combination of non-pharmacologic and pharmacologic strategies.
- Non-pharmacologic strategies include:
- Pharmacologic treatment options include:
- Fludrocortisone, which expands the extravascular body fluid volume and improves alpha-adrenergic sensitivity
- Midodrine, a peripheral, selective alpha1-adrenergic agonist that causes arterial and venous vasoconstriction
- Atomoxetine, which blocks norepinephrine reuptake in nerve terminals and can improve upright blood pressure
- Pyridostigmine, which facilitates cholinergic neurotransmission in autonomic ganglia
- Droxidopa, a pressor agent that can be used if traditional agents are needed 3, 4, 5, 7
Considerations for Patients with Comorbidities
In patients with comorbidities such as hypertension, the management of orthostatic hypotension can be challenging. It is essential to remove drugs that can worsen orthostatic hypotension and to use antihypertensives that are preferable for these patients, such as angiotensin receptor blockers and calcium channel blockers 7.
Patient-Oriented Approach
A patient-oriented approach that emphasizes education and non-pharmacologic strategies is critical in the management of orthostatic hypotension. The therapeutic goal is to improve postural symptoms, standing time, and function rather than to achieve upright normotension, which can lead to supine hypertension 6.