Nonhypoglycaemic presyncope in a diabetic woman

Case scenario

I recently had an interesting visit from a 67-year-old diabetic woman and her husband. Over the past few months my patient had been having ‘spells’ whereby she felt dizzy and faint. Her husband had been obligingly administering her glucose, which she claimed helped slightly when she had a ‘little lie down’. She denied any focal neurological symptoms. Examination revealed normal gait and co-ordination.

Her blood pressure was 130/70 mmHg lying down and 95/60 mmHg standing. I assume that her symptoms are due to orthostatic hypotension. The laboratory tests revealed a raised HbA1c. The patient takes an oral hypoglycaemic medication but no other treatment.

What is the best management of postural hypotension in a diabetic patient? Is fludrocortisone an option or will it adversely interfere with her blood glucose control? What can be done to prevent further autonomic deterioration?