Intravenous Hydration for Management of Medication-Resistant Orthostatic Intolerance in the Adolescent and Young Adult

Abstract

Orthostatic intolerance (OI) is common in teenagers (T) and young adults (A). Despite treatment with oral fluids, medication, and exercise, a significant number have symptoms from multiple organ systems and suffer low quality of life (QOL). Previous studies showed that acute intravenous (IV) hydration (IH) could help restore orthostatic tolerance; however, no data are available about the intermediate-term effects of IH. We therefore studied the efficacy of IH to improve QOL and manage medication-refractory OI patients. Our study population consisted of 39 patients (mean age = 16.1 ± 3.3) years; thirty-two were female. Average number of medications failed = 3.1. Average QOL score on self-reported OI questionnaire was 4.2 (normal QOL = 10). IV hydration consisted of normal saline (1-2 l/day, 3-7 days/week). 1) Orthostatic testing revealed Postural Orthostatic Tachycardia (24), Neurally Mediated Hypotension (14) or OI (1). 2) Average orthostatic change in heart rate was 48 ± 18 bpm. 3) IH was performed via intermittent IV access (10), PICC line (22), and Port (7). 4) Duration of IH varied from 1 week to 3.8 years (mean = 29 ± 47 weeks). 5) Overall, 79 % (n = 31) demonstrated clinically improved self-reported QOL. 6) Six patients who discontinued IH requested to restart treatment. (7) Complications consisted of upper extremity deep vein thrombosis (n = 3) and infection (n = 4). IH is an effective therapy to improve QOL in T&A with medication-resistant OI. Most patients continued to report improved QOL once IH was discontinued. IH should be considered a therapeutic option in medication-resistant OI patients with low QOL.

Myalgic Encephalomyelitis/Chronic Fatigue Syndrome Diagnosis and Management in Young People: A Primer

“…Because individuals with OI are usually hypovolemic, they can withstand a rapid infusion of 2 L of normal saline over 1–2 h. Infusions provide a more rapid restoration of intravascular volume and a larger intake of sodium than is possible orally. Peripheral IV lines are preferred, as the placement of PICC or central lines poses a risk of local infection or bacteremia (129). The efficacy of this practice has not been studied in a randomized trial and more formal study is needed.…”

Cardiovascular autonomic dysfunction in Ehlers–Danlos syndrome—Hypermobile type

“…Dihydroxyphenylserine titrated 100–200 mg three times daily reduces OH (Level I evidence). Octreotide given subcutaneously in doses of 25–150 μg for 30 min before a meal may be used to reduce postprandial OH. Tolerance of upright posture and autonomic tone may improve after the administration of 1–2 L of intravenous normal saline infused over 1–2 hr [Burklow et al, ; Takenaka et al, ], or other forms of sodium loading [Rosen and Cryer, ]. Some physicians use IV saline to manage acute episodic exacerbations of OI [Moak et al, ]. The use of IV saline on a weekly basis can help improve function for selected individuals who are intolerant of or unresponsive to medications.…”

Dietary Sodium Intake and Migraine: Is Salt the Answer?

“…11 In some patients with medication-resistant POTS and neurally mediated hypotension, intravenous saline has been used as an effective therapy. 12 In our patient population with both migraine and POTS, we observed that treatment of POTS with high sodium and fluid intake and pharmacotherapy, which often includes a low dose of a beta blocker in combination with fludrocortisone (an aldosterone analog that increases plasma volume through enhanced sodium resorption), can also improve headache frequency and severity. Conversely, when we effectively manage chronic migraine with prophylactic headache therapy, symptoms of POTS tend to concurrently improve.…”

“…The first‐line therapeutic intervention for patients with autonomic disorders is plasma volume expansion via increased water and sodium consumption, which are effective nonpharmacologic measures for raising blood pressure, reducing orthostatic blood pressure drop, and ameliorating postural tachycardia . In some patients with medication‐resistant POTS and neurally mediated hypotension, intravenous saline has been used as an effective therapy …”