Pharmacotherapy Case Study 4: Hypotension By: Dr. Nehad Ahmed

 

Chief Complaint:

The patient presents with complaints of dizziness and lightheadedness, especially when standing up, and occasional fatigue. The symptoms have been present for the last few days and are interfering with daily activities.

Subjective Data:

History of Present Illness (HPI):
The patient reports feeling lightheaded and dizzy when standing from a sitting or lying position, with symptoms worsening in the morning. The dizziness is brief but intense, often lasting a few seconds to a minute. The patient denies experiencing fainting or syncope. There is no associated chest pain, shortness of breath, or palpitations. The patient also mentions feeling unusually fatigued over the past few days but does not have any difficulty with normal daily tasks. The symptoms have not improved with rest.

Past Medical History (PMH):

Orthostatic hypotension (previously diagnosed 2 years ago)

Type 2 diabetes mellitus

Obesity (BMI 34 kg/m²)

Gastroesophageal reflux disease (GERD)

Mild depression (managed with counseling)

No history of cardiovascular disease, such as heart failure or arrhythmias.

Medications:

Metformin 500 mg twice daily

Losartan 50 mg daily

Omeprazole 20 mg daily

Sertraline 50 mg daily

Occasionally takes over-the-counter acetaminophen for headaches.

Allergies:

No known drug allergies.

Family History:

Father with hypertension and type 2 diabetes

Mother with a history of hypothyroidism

No significant history of heart disease or stroke.

Social History:

Non-smoker

Occasional alcohol use (1-2 drinks per week)

Sedentary lifestyle, no regular exercise

Diet with a higher intake of processed foods and low in vegetables

Recently experienced increased stress related to work

Review of Systems:

Cardiovascular: No chest pain, palpitations, or edema.

Neurological: Lightheadedness on standing, no weakness or numbness.

Respiratory: No shortness of breath or cough.

Gastrointestinal: No nausea, vomiting, or abdominal pain.

Endocrine: No recent changes in appetite, weight, or energy levels outside of fatigue.

Objective Data:

Vital Signs:

Blood Pressure: 100/60 mmHg (seated), drops to 90/58 mmHg when standing

Heart Rate: 78 bpm

Respiratory Rate: 16 breaths/min

Temperature: 36.7°C

Oxygen Saturation: 98% on room air

Weight: 95 kg (BMI 34 kg/m²)

Height: 165 cm

Physical Exam:

General: Overweight, in mild distress due to dizziness but not in acute discomfort.

Cardiovascular: Regular heart rate, no murmurs or gallops. No jugular venous distention.

Neurological: Alert and oriented, cranial nerves intact. No signs of focal neurological deficits. No signs of orthostatic changes other than mild dizziness on standing.

Respiratory: Clear lungs bilaterally, no wheezing or crackles.

Abdomen: Soft, non-tender, no hepatomegaly or splenomegaly.

Extremities: No edema, pulses normal bilaterally.

Skin: Warm and dry, no rashes or lesions.

Laboratory Results:

Electrolytes: Sodium 139 mEq/L, Potassium 4.2 mEq/L

Creatinine: 0.9 mg/dL (normal for baseline)

Blood Glucose: 112 mg/dL (fasting)

Complete Blood Count (CBC): Hemoglobin 13.5 g/dL, Hematocrit 40%, Platelets 230,000/μL

Thyroid Function Tests: Normal TSH, T3, and T4 levels

Urinalysis: Negative for protein, glucose, or blood.

Additional Tests:

ECG: Normal sinus rhythm, no evidence of arrhythmias or ischemia.

Echocardiogram: Normal left ventricular ejection fraction (LVEF), no signs of valvular disease or heart failure.

Assessment:

The patient’s symptoms of dizziness, lightheadedness upon standing, and fatigue are indicative of orthostatic hypotension, which is likely exacerbated by the patient’s existing use of antihypertensive medication (Losartan). The patient’s blood pressure readings, particularly the significant drop upon standing (90/58 mmHg), confirm the diagnosis of orthostatic hypotension.

The patient has risk factors for hypotension, including:

Antihypertensive therapy (Losartan) which could be contributing to low blood pressure, especially in the context of postural changes.

Obesity and diabetes mellitus, which are known to increase the risk of vascular dysfunction and may contribute to the autonomic dysfunction that can exacerbate orthostatic hypotension.

The recent increased stress might also be a contributing factor, as stress can affect blood pressure regulation.

The patient’s blood glucose level and thyroid function are within normal limits, ruling out endocrinopathies as causes of the symptoms.

Plan:

Immediate Management:

Adjust antihypertensive therapy:

Consider lowering the dose of Losartan or switching to a different antihypertensive agent if blood pressure remains too low after other interventions.

Discontinue unnecessary medications (e.g., consider discontinuing Omeprazole if no clear gastrointestinal issues, as it may contribute to dehydration or electrolyte imbalances).

Increase fluid intake: Advise the patient to drink plenty of fluids, particularly water, to improve blood volume and support blood pressure regulation.

Increase salt intake cautiously (if no contraindications, such as kidney disease) to support vascular volume.

Compression stockings: Recommend the use of compression stockings to help with blood return to the heart and prevent pooling in the legs.

Pharmacotherapy Adjustments:

If symptoms persist despite lifestyle changes, consider adding a midodrine (alpha-agonist) 2.5 mg 3 times daily as needed for orthostatic hypotension.

Fludrocortisone 0.1 mg daily, if conservative measures are insufficient, to increase blood volume and improve pressure regulation.

Lifestyle Modifications:

Dietary adjustments: Encourage a balanced diet with a focus on hydration and salt intake (within safe limits).

Exercise: Recommend mild aerobic activity, such as walking, to improve vascular tone and circulation.

Gradual postural changes: Advise the patient to rise slowly from sitting or lying positions and to avoid prolonged standing.

Elevate the head of the bed slightly at night to help with orthostatic symptoms.

Monitoring & Follow-up:

Frequent blood pressure monitoring at home to track changes, particularly in the morning and after standing up.

Follow-up in 1-2 weeks to assess the effectiveness of interventions and adjust treatment if necessary.

Monitor electrolytes and renal function in 4-6 weeks to ensure that pharmacological interventions are not causing adverse effects.

Patient Education:

Educate the patient on orthostatic hypotension, explaining the role of medications, hydration, and postural changes in managing symptoms.

Signs of dehydration: Advise the patient to watch for symptoms such as dry mouth, fatigue, and dark-colored urine.

Encourage the patient to avoid alcohol or to limit intake as it can exacerbate hypotension.

Referral:

Consider referral to a cardiologist or neurologist if symptoms persist despite adjustments or if additional evaluation of autonomic dysfunction is warranted.

Discussion:

Hypotension, especially orthostatic hypotension, is a common problem in patients taking antihypertensive medications, especially when combined with comorbid conditions like diabetes and obesity. Orthostatic hypotension can result in dizziness, fatigue, and an increased risk of falls. The goal of treatment is to address both the underlying cause (e.g., medication adjustments, lifestyle changes) and symptom management (e.g., increased hydration, compression garments).

The patient’s case emphasizes the importance of regular blood pressure monitoring, especially when medications can cause fluctuations in blood pressure, and a holistic approach that includes both pharmacological and non-pharmacological strategies.

Prognosis:
With appropriate adjustments to medications and lifestyle changes, the patient's symptoms of dizziness and fatigue can likely be managed effectively. However, the patient will need to continue close follow-up and monitoring to prevent recurrence of hypotensive episodes.