Combination Therapy for Postprandial and Orthostatic Hypotension in an Elderly Patient With Type 2 Diabetes Mellitus

To the Editor: Management of postprandial hypotension (PPH) and orthostatic hypotension (OH) in elderly persons and patients with diabetes mellitus is problematic. We present the case of an elderly patient with type 2 diabetes mellitus with severe symptomatic PPH and OH who was successfully treated with a combination of acarbose and use of an inflatable band. A 72-year-old man with syncope was referred to Osaka Medical College. He had been diagnosed with diabetes mellitus at the age of 42; at the age of 55, he was no longer able to control his blood glucose level using oral medications, so it was recommended that he begin insulin treatment. At the age of 62, he suffered his first attack of syncope after eating, and by the time he was admitted to the hospital, the attacks had become more frequent, especially upon standing and after meals. Upon admission, he weighed 52 kg, and his height was 161 cm. His pulse rate was 78 beats/min and regular, and his supine and standing blood pressures (BPs) were 124/78 mmHg and 66/40 mmHg, respectively. The patient's tendon reflexes and vibratory sensation were diminished at the ankles, and motor and sensory nerve conduction velocities were similarly reduced in the lower extremities. Preproliferative diabetic retinopathy was also noted. Laboratory tests revealed a serum creatinine level of 0.84 mg/dL, fasting plasma glucose concentration of 151 mg/dL, a hematocrit of 38.5%, and a hemoglobin A1c level of 7.5%. The urine albumin-creatinine index was in the microalbuminuric range (28.7 mg/dL of creatinine). Electrocardiographic and echocardiographic findings were normal. The coefficient of variation in his electrocardiographic RR interval was 1.08% during controlled deep breathing. Valsalva test and cold pressor test findings were normal. Magnetic resonance imaging showed several lacunae infarctions, and magnetic resonance angiography showed 75% stenosis in the left carotid artery. The patient was fed standard meals with the following estimated caloric values and carbohydrate contents: breakfast, 360 kcal and 65 g; lunch, 420 kcal and 55 g; and dinner, 420 kcal and 55 g, respectively. Twenty-four-hour automatic BP monitoring (TM2425, COLIN Corp., Komaki, Japan) revealed that the patient's sitting systolic BP decreased 34 mmHg within 60 minutes after breakfast, 39 mmHg after lunch, and 18 mmHg after dinner. On the basis of previous reports,1 a regimen of acarbose (300 mg/d: 100 mg three times daily 20 minutes before a meal) was prescribed for the patient. Two weeks later, his postlunch symptoms disappeared, and the magnitude of the fall in BP after each meal was also reduced. A head-up tilt test (70°) administered before treatment revealed severe OH (Figure 1A). Although the PPH clearly improved after acarbose treatment, the OH remained (Figure 1B). As a result, and according to previous findings,2 fitting the patient with an inflatable band to induce abdominal compression was considered. The patient was subjected to a fasting head-up tilt test with and without the inflatable band in place. With the inflatable band in place, BP monitoring (Portapres, FMS, Arnhem, the Netherlands) revealed improvement in the initial drop in BP that occurred upon standing. The time that the patient could remain standing without symptoms improved from 390 seconds before treatment to 540 seconds after acarbose treatment to longer than 700 seconds after treatment with acarbose and abdominal compression (Figure 1C). Blood pressure (BP) measurements during tilt test were assessed using a BP monitoring system. X-axis represents BP (mmHg) and Y-axis represents time (seconds). (A) Before any treatment, (B) after acarbose administration, and (C) after treatment with acarbose and use of an abdominal band. OH is reportedly found in 24% of elderly persons.2 PPH is diagnosed more frequently, in as many as 34% of elderly persons, and both disorders are diagnosed in approximately 10% of elderly persons. It has been reported that PPH and OH coexist in more than 10% of patients with long-term type 2 diabetes mellitus.4 OH and PPH are associated with increased morbidity and mortality and possibly cognitive decline.5,6 Combined use of acarbose and abdominal compression may be effective for the treatment of PPH and OH, because these treatments act in different ways on the splanchnic circulation. Acarbose, which is an alpha-glucosidase inhibitor, reportedly improved PPH in patients with type 1 and 2 diabetes mellitus.1,7 By delaying carbohydrate absorption and reducing peak postprandial plasma glucose levels, acarbose may also suppress the release of gastrointestinal vasodilatory peptides, thereby limiting expansion of the splanchnic pool.8–10 In contrast, an inflatable band directly reduces the pooling of splanchnic blood and increases central venous pressure, thereby facilitating stroke volume and cardiac output and leading to improved OH.2 The present case suggests that a combination of acarbose treatment and use of an inflatable band is effective for treatment of PPH and OH. Financial Disclosure: No financial support to state. Author Contributions: All participated in all aspects of the paper. Sponsor's Role: None.