ODP184 Diabetic Postural Dizziness,Hyperlactatemia,Hyponatremia-Role of Fludrocortisone
Authors: Singh Santosh 
Published: November 2022

Background

Fludrocortisonehas been used in the management of idiopathic postural hypotension and occasionally in diabetic postural hypotension. [1]Enhanced sympathetic nervous system(SNS) activity consequent upon autonomic dysfunction has been linked with the development and maintenance of hyperlactatemia and lactic acidosis(converted to lactate at physiological pH). [2]The mineralocorticoid property of fludrocortisone is utilized inthe management of hyponatremia and hypovolemia. [3] Clinical Cases: Hereby,two T2DM patients are being discussed where fludrocortisone(0.1 mg/d) provided symptomatic relief in postural dizziness. The first patient was a 60 year-old obese, euthyroid,hypertensive male having diabetes(insulin requiring)for the last 30 years with normal kidney function and complaints of frequent postural dizziness and occasional fainting attacks,although,there was no postural drop of blood pressure or tachycardia. He had lactate levels of 4 to 5 mmol/L with normal pH and bicarbonate. He had symptomatic relief with fludrocortisone(being taken for the last four years) with no rise of blood pressure or change in electrolytes or lactate levels. He had associated epigastric fullness and erectile dysfunction(suggestive of autonomic neuropathy). The other patient was an 80 year-old male, euthyroid,normotensive,insulin requiring diabetic for last 27 years with normal kidney function. He was operated for right adrenocortical carcinoma almost 30 years ago which was uneventful till three years ago when he presented with breathlessness and was diagnosed as having adrenal metastasis(immunohistochemistry)in lungs. Thereafter,he developed postural dizziness(despite being on ivabradine),cognitive decline along with abdominal fullness and urinary incontinence(suggestive of autonomic neuropathy). He had hyponatremia(possibly due to SIADH) which rose from 117 mmol/L on 15 mg/d tolvaptan to 123 mmol/L on 30 mg/d. There was significant relief in postural dizziness and slight improvement in serum sodium(rose to 124mmol/L)with 0.10 mg/d fludrocortisone. A lower dose of fludrocorisone is required for symptomatic relief in diabetic postural hypotension (efferent fibre lesion affecting SNS, possibly with reduced renin secretion in response to erect posture) as compared to idiopathic postural hypotension(afferent or central lesion). Fludrocortisone has been reported to increase serum sodium in short-term studies whereas serum sodium remained in normal range and there was no increase in blood pressure in long-term studies. [1] Conclusion: These cases highlight the benefit of fludrocortisone in the management of diabetic postural dizziness and hyponatremia and the rare association of hyperlactatemia with autonomic dysfunction.

References

1. Campbell IW,Ewing DJ,Clarke BF: Therapeutic experience with fludrocortisone in diabetic postural hypotension. British Medical Journal,1976,1,872-874. 2. Monteiro Carlos ETB: Autonomic Dysfunction and Increased Lactate Production with Accumulation in the Body: The Key Factors for the Development of Rheumatoid Arthritis. Arthritis,252,Feb,2019. 3. Mistry AM,Mistry EA,Ganesh Kumar N et. al.: Corticosteroids in the Management of Hyponatremia,Hypovolemia,and Vasospasm in Subarachnoid Hemorrhage: A Meta-Analysis. Cerebrovasc Dis,2016,42,263-271.

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