From the Guidelines
Orthostatic hypotension in CIDP treatment requires a multifaceted approach, including non-pharmacological measures and pharmacologic interventions, with midodrine and droxidopa being FDA-approved treatments, as noted in the most recent study 1.
Treatment Options
The treatment of orthostatic hypotension in Chronic Inflammatory Demyelinating Polyneuropathy (CIDP) involves both management of the underlying condition and specific interventions for blood pressure regulation.
- Non-pharmacological approaches are crucial and include:
- Increasing fluid intake (2-3 liters daily)
- Adding salt to the diet (8-10g daily)
- Wearing compression stockings
- Performing physical countermaneuvers like leg crossing when standing
- For medication management, options include:
- Fludrocortisone, which helps increase sodium retention and blood volume
- Midodrine, an alpha-agonist that increases peripheral vascular resistance
- Droxidopa, for severe cases, which may help improve symptoms of neurogenic orthostatic hypotension
Rationale
These interventions should be implemented alongside the primary CIDP treatment (IVIg, corticosteroids, or plasma exchange) because the orthostatic symptoms occur due to the effect of autonomic nerve fibers being affected in CIDP, disrupting normal blood pressure regulation when changing positions 1.
Monitoring and Precautions
Regular monitoring of blood pressure in both lying and standing positions is essential to assess treatment effectiveness, and patients should be cautioned about potential supine hypertension with these medications, particularly when lying flat at night, as highlighted in 1 and 1.
Additional Considerations
Other treatments like pyridostigmine and octreotide may be beneficial in specific cases, such as patients refractory to other treatments or with postprandial hypotension, as discussed in 1. However, the primary approach should focus on the most effective and least invasive methods first, considering the patient's overall health status and potential for side effects.
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 treatment options for orthostatic hypotension in Chronic Inflammatory Demyelinating Polyneuropathy (CIDP) include:
- Midodrine: a medication that can help increase blood pressure and alleviate symptoms of orthostatic hypotension.
- Non-pharmacologic treatment: such as support stockings, fluid expansion, and lifestyle alterations. It is essential to note that midodrine should be used with caution and under close medical supervision, as it can cause marked elevation of supine blood pressure 2.
From the Research
Treatment Options for Orthostatic Hypotension in CIDP
The treatment options for orthostatic hypotension in Chronic Inflammatory Demyelinating Polyneuropathy (CIDP) can be categorized into non-pharmacologic and pharmacologic measures.
- Non-pharmacologic measures:
- Pharmacologic measures:
- Midodrine: a prodrug that increases standing systolic blood pressure and improves standing time and energy level 6, 5
- Fludrocortisone: a mineralocorticoid that increases blood volume and blood pressure, considered first- or second-line pharmacological therapy for orthostatic hypotension 7, 5
- Droxidopa: a first-line medication for orthostatic hypotension 5
Considerations for Treatment
When treating orthostatic hypotension in CIDP, it is essential to consider the underlying cause and adjust potentially causative medications 3, 5. The treatment goals are to reduce symptoms and improve quality of life 5. A combination of non-pharmacologic and pharmacologic measures may be necessary to achieve optimal results 3, 4, 5.