The treatment of idiopathic orthostatic hypotension: a combined fludrocortisone and flurbiprofen regime.

We report our experience in the management of idiopathic orthostatic hypotension using the prostaglandin synthetase inhibitor, flurbiprofen. In five subjects with proven autonomic failure the effect on blood pressure of the addition of flurbiprofen (or fludrocortisone) to the previous drug regime was assessed. Both lying and standing blood pressure were seen to rise with fludrocortisone treatment although the change in standing blood pressure was not statistically significant. Flurbiprofen, in contrast, produced no change in lying blood pressure but a significant rise in standing blood pressure. Digital blood flow measurements were made on three subjects before and after flurbiprofen and a dose-related reduction in post-occlusive reactive hyperaemia was demonstrated suggesting an effect of this drug on precapillary smooth muscle tonus. Two patients failed to maintain a long-term response to treatment with flurbiprofen and fludrocortisone but have been helped by the addition of I) ephedrine or II) tyramine an monoamine oxidase inhibitor (phenelzine). We recommend a stepwise approach to treatment in this condition commencing with flurbiprofen and adding fludrocortisone later if necessary. This approach would appear to offer the maximum benefit with a minimum of side effects.