When to start salt tablets for orthostatic hypotension?

Salt Tablets for Orthostatic Hypotension Management

Salt tablets should be initiated for orthostatic hypotension when non-pharmacological measures alone are insufficient, particularly when patients have documented orthostatic symptoms despite adequate hydration, and should be combined with increased fluid intake of 2-3L per day. 1, 2

Initial Management Approach

First-line Non-pharmacological Interventions

• Ensure adequate fluid intake of 2-3L per day 2
• Physical counterpressure maneuvers (leg crossing, squatting, muscle tensing) 2
• Compression stockings (30-40 mmHg pressure, thigh-high) applied before rising 2
• Head-up tilt sleeping (10° elevation) 2
• Regular exercise of leg and abdominal muscles 2
• Dietary modifications:
  • Small, frequent meals (4-6 per day)
  • Reduced carbohydrate content
  • Increased dietary fiber and protein 2
  • Avoiding alcoholic beverages 2

When to Start Salt Supplementation

Indications for Salt Tablets

1. Persistent orthostatic symptoms despite adequate hydration 1, 2
2. Documented orthostatic hypotension (drop in BP ≥20/10 mmHg within 3 minutes of standing) 1
3. Patients with dehydration and orthostatic intolerance 1

Recommended Salt Intake

• Increase dietary sodium to 6-10g daily (unless contraindicated) 2
• Salt tablets typically dosed as NaCl 3g twice daily in addition to regular diet 3

Monitoring Effectiveness

• Evaluate based on symptom improvement rather than absolute BP values 2
• Monitor daily weight and electrolytes (particularly sodium and potassium) 2
• Check both supine and standing BP regularly to assess efficacy 2

Important Considerations and Contraindications

Contraindications to Salt Supplementation

• Heart failure 1
• Uncontrolled hypertension 1
• Chronic kidney disease 1

Synergistic Approaches

• Combine salt tablets with rapid water ingestion (500ml, 30 minutes before anticipated orthostatic stress) 2, 4
• Consider that water alone may provide a stronger immediate pressor response than salt water in some patients 4
• For enhanced effectiveness, salt tablets may be combined with fludrocortisone in refractory cases 2, 5

Special Populations

• In diabetic patients with autonomic dysfunction, focus on glucose control alongside salt supplementation 2
• Pregnant patients should prioritize volume expansion with intravenous fluids for acute management 2
• In elderly patients, start with lower doses and monitor closely for supine hypertension 2

Progression to Pharmacological Therapy

If salt supplementation with adequate hydration fails to control symptoms, consider adding:

1. Fludrocortisone - stimulates renal sodium retention and expands fluid volume 2
2. Midodrine (5-20mg three times daily) - increases vascular tone 2
3. Droxidopa (100-600mg TID) - strongly recommended for neurogenic orthostatic hypotension 2
4. Pyridostigmine (30mg 2-3 times daily) - for refractory cases 2

Common Pitfalls to Avoid

• Focusing on BP numbers rather than symptom improvement 2
• Overlooking non-pharmacological measures before starting salt tablets 2
• Inadequate monitoring for supine hypertension 2
• Failing to recognize vitamin deficiencies (e.g., scurvy) that can contribute to orthostatic hypotension 6

Salt tablets represent an important intervention for orthostatic hypotension but should be implemented as part of a comprehensive approach that begins with non-pharmacological measures and progresses to medication if needed.