Table 7.

Cardiovascular autonomic dysfunction

Symptom	Treatment approach
Orthostatic hypotension	Non-pharmacological methods should be tried in all patients. Pharmacological treatment includes midodrine (first line) followed by fludrocortisone then pyridostigmine. Regularly review need for pharmacological treatment as progressive loss of mobility decreases the duration of being upright/standing.
Supine hypertension	Elevate head of the bed by at least 30° overnight. Avoid supine positions during the day where possible. The last midodrine dose should be no less than 4 hours before bed. A small carbohydrate-rich meal in the late evening may help. Take a short-acting antihypertensive medication (eg, nifedipine/losartan) before bed.
Postprandial hypotension	Encourage small, low carbohydrate meals but increase the frequency of eating. Time the midodrine dosing around meals. Consider using acarbose and octreotide, although octreotide is only available for prescription in specialist centres for this indication.