From the Guidelines
Salt tablets can be used to help manage orthostatic hypotension, as they increase sodium intake, which helps expand blood volume and maintain blood pressure when changing positions. According to the 2023 ACC expert consensus decision pathway on comprehensive multidisciplinary care for the patient with cardiac amyloidosis 1, increased salt/fluid intake, including salt tablets, can be beneficial for managing orthostatic hypotension. However, it is essential to use them cautiously in people with heart failure, kidney disease, or hypertension, and only under medical supervision.
Key Considerations
- Typical recommendations include sodium chloride tablets (1-2 grams, 2-3 times daily with meals and plenty of water) 1.
- Start with a lower dose and increase gradually to avoid side effects like nausea or fluid retention.
- Salt tablets work best when combined with adequate fluid intake (2-3 liters daily) and other measures like compression stockings, slow position changes, and avoiding prolonged standing.
- Regular monitoring of blood pressure and electrolyte levels is crucial when using salt tablets as a treatment.
Alternative and Additional Measures
- Other options for managing orthostatic hypotension include fludrocortisone, midodrine, or droxidopa, although these interventions may be poorly tolerated in patients with heart failure from cardiac involvement 1.
- Pyridostigmine is another option for orthostatic hypotension without the risks of fluid retention or supine hypertension 1.
- Compression with knee- or thigh-high compression socks or stockings, and abdominal binders (in patients who can tolerate them) can be helpful without the risk of drug side effects or interactions 1.
Important Precautions
- Older patients with amyloidosis are at greater risk for side effects of these medications, and consultation with a geriatric specialist is recommended 1.
- The Beers Criteria from the American Geriatric Society is a helpful guide that outlines potentially inappropriate medication use in older adults 1.
From the Research
Management of Orthostatic Hypotension
- Orthostatic hypotension (OH) is a decline in blood pressure that occurs when one moves from a lying to a standing position, resulting in symptoms of cerebral hypoperfusion, such as lightheadedness and syncope 2.
- The goal of therapy is to relieve symptoms, and nonpharmacologic approaches are preferred, including increasing sodium intake, avoiding rapid postural changes, and wearing elastic garments 2.
Role of Salt Intake
- Increasing dietary salt intake is often recommended to improve orthostatic tolerance, as it can help increase blood volume and blood pressure 3.
- However, there is no empirical evidence to support this recommendation, and more research is needed to understand the effects of high salt intake on orthostatic hypotension 3.
- A high salt diet of 150-200 mmol Na+ d-1 was administered in combination with other treatments, such as sleeping in the head-up tilt position and fludrocortisone, to improve orthostatic tolerance and blood pressure 4.
Treatment Options
- Fludrocortisone is a mineralocorticoid that increases blood volume and blood pressure, and is considered a first- or second-line pharmacological therapy for orthostatic hypotension 5.
- The evidence for the effectiveness of fludrocortisone is very uncertain, and more research is needed to understand its effects on blood pressure, orthostatic symptoms, and adverse events 5.
- Other nonpharmacologic measures, such as increasing fluid intake, wearing compression stockings, and avoiding heat, can also be effective in managing orthostatic hypotension 6.
Combination Therapy
- Combination therapy, such as sleeping in the head-up tilt position and fludrocortisone, can be effective in minimizing orthostatic symptoms and increasing orthostatic blood pressure 4.
- A combination of nonpharmacologic and pharmacologic therapies can often adequately manage orthostatic hypotension, although the most effective approach may vary depending on the individual patient 2.