Patients often have postprandial accentuation of OH. This can occur with any type of neurogenic OH, but is particularly common with diabetic autonomic neuropathy. It often occurs on the background of gastrointestinal autonomic neuropathy, highlighting the great importance of the splanchnic-mesenteric bed in orthostatic BP control. This is a large-volume (20-30% of total blood volume) capacitance bed that, unlike other venous beds, is exquisitely baroreflex responsive. Some patients with mild postprandial OH discover that the worsening can be reduced by frequent small meals, and some find that certain foods are most troublesome and should be avoided. Some patients report that hot drinks or hot food need to be avoided. Carbohydrates are especially troublesome. Ibuprofen, 400-800 mg, or indomethacin, 25-50 mg, with the meal is well-tolerated and should be tried. The next step is the administration of a vasoconstrictor such as midodrine, 10 mg. A problem with vasoconstrictors is the aggravation of gastroparesis. Rarely, symptoms suggestive of gut ischemia may occur. If all the approaches are inadequate, the somatostatin analog octreotide can be administered with the meal. The dose is 25 ^g by subcutaneous injection. The dose can be increased if necessary to 100-200 ^g. This is the most efficacious agent but requires parenteral administration.
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