Water drinking as a treatment for orthostatic syndromes, 2002, John R Shannon et al

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salin

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Water drinking as a treatment for orthostatic syndromes

John R Shannon, Andre Diedrich, Italo Biaggioni, Jens Tank, Rose Marie Robertson, David Robertson, Jens Jordan


Abstract

Purpose: Water drinking increases blood pressure in a substantial proportion of patients who have severe orthostatic hypotension due to autonomic failure. We tested the hypothesis that water drinking can be used as a practical treatment for patients with orthostatic and postprandial hypotension, as well as those with orthostatic tachycardia.

Subjects and methods: We studied the effect of drinking water on seated and standing blood pressure and heart rate in 11 patients who had severe orthostatic hypotension due to autonomic failure and in 9 patients who had orthostatic tachycardia due to idiopathic orthostatic intolerance. We also tested the effect of water drinking on postprandial hypotension in 7 patients who had autonomic failure. Patients drank 480 mL of tap water at room temperature in less than 5 minutes.

Results: In patients with autonomic failure, mean (+/- SD) blood pressure after 1 minute of standing was 83 +/- 6/53 +/- 3.4 mm Hg at baseline, which increased to 114 +/- 30/66 +/- 18 mm Hg (P <0.01) 35 minutes after drinking. After a meal, blood pressure decreased by 43 +/- 36/20 +/- 13 mm Hg without water drinking, compared with 22 +/- 10/12 +/- 5 mm Hg with drinking (P <0.001). In patients with idiopathic orthostatic intolerance, water drinking attenuated orthostatic tachycardia (123 +/- 23 beats per minute) at baseline to 108 +/- 21 beats per minute after water drinking ( P <0.001).

Conclusion: Water drinking elicits a rapid pressor response in patients with autonomic failure and can be used to treat orthostatic and postprandial hypotension. Water drinking moderately reduces orthostatic tachycardia in patients with idiopathic orthostatic intolerance. Thus, water drinking may serve as an adjunctive treatment in patients with impaired orthostatic tolerance.

https://www.amjmed.com/article/S0002-9343(02)01025-2/abstract

From 2002
 
"Because excessive water ingestion might lead to water intoxication, we ususally recommend that the daily fluid intake be in the range of 2 to 3 liters. However, the timing of the water intake is of major importance. Patients should drink most of the water when their orthostatic symptoms tend to be worst, such as before arising in the morning and before meals."

I found this interesting because it explicitly recommends drinking almost 500 ml of water at once.
I've never heard that before.
I can't try it out because I no longer suffer from POTS/OI, but I would find it very interesting to know if this tip helps anyone.
 
I have not read beyond the abstract but I would like to see much more detail before taking this at face value. If it works it should be possible to construct a dose response curve so that the optimum dose can be found - rather than just guessing 500ml, which might be entirely unnecessary. (And the rise in blood pressure might be due to an adrenaline and cortisol surge associated with having to keep getting up to pee!)

I would also like to see how long this effect lasts and whether it leaves the person waterlogged, with a raised weight or just gets peed out in 45 minutes.

I drink 500ml before getting out of bed anyway, but I prefer two nice cups of tea.
 
salin said:
Patients should drink most of the water when their orthostatic symptoms tend to be worst, such as before arising in the morning and before meals
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I seem to drink more liquid than average, and empty a 0.6 litre bottle first thing.

But I don't get OI on rising or eating anyway, I get it from standing on the spot for more than about 30 to 40 seconds at any time of day or night. It's ME/CFS rather than autonomic failure.
 
Jonathan Edwards said:
I have not read beyond the abstract but I would like to see much more detail before taking this at face value. If it works it should be possible to construct a dose response curve so that the optimum dose can be found - rather than just guessing 500ml, which might be entirely unnecessary. (And the rise in blood pressure might be due to an adrenaline and cortisol surge associated with having to keep getting up to pee!)

I would also like to see how long this effect lasts and whether it leaves the person waterlogged, with a raised weight or just gets peed out in 45 minutes.

I drink 500ml before getting out of bed anyway, but I prefer two nice cups of tea.
Click to expand...
When I had OI, I drank water in the morning, but never that much.
Dr. Boschmann from Charité Berlin gave me a printout of this study.
Unfortunately, I am currently unable to understand the finer details, but I would be happy to send you a scan, if interested.
 
Kitty said:
I seem to drink more liquid than average, and empty a 0.6 litre bottle first thing.

But I don't get OI on rising or eating anyway, I get it from standing on the spot for more than about 30 to 40 seconds at any time of day or night. It's ME/CFS rather than autonomic failure.
Click to expand...
It's interesting how different it is!
My OI manifested itself as severe dizziness, especially when standing up, and as intense pressure in my head when sitting down.
Standing and walking were less of a problem, and as the day progressed (with plenty of lying down), it got better and better towards the evening.
 
Their protocol raises certain questions:

Vasoactive medications and fludrocortisone were discontinued at least 5 half-lives before testing. Studies were conducted at least 2.5 hours after breakfast or lunch. Patients were not permitted to drink for at least 1.5 hours before testing. They ate a diet that contained 150 mmol of sodium and 70 mmol of potassium for at least 3 days before testing. In 11 patients with primary autonomic failure, we measured the dose-response relation to water drinking (n = 8) and the effect of drinking 480 mL of tap water at room temperature (20°C) in less than 5 minutes on the orthostatic blood pressure response. After completion of these tests, we assessed the effect of drinking 480 mL of tap water at room temperature in less than 5 minutes on postprandial hypotension in 7 other patients. We also measured the effect of drinking 480 mL of tap water at room temperature in less than 5 minutes on orthostatic heart rate and blood pressure response in the 9 patients with idiopathic orthostatic intolerance.

Stopping fludrocortisone before testing might produce an artifactual situation. Not being allowed to drink for 1.5hrs also seems to skew things. Taken together it would be a bit like deliberately drying someone out. They did do a dose response study but frustratingly give no data on the results. They say some people had a response to just 120ml.
 
Jonathan Edwards said:
Stopping fludrocortisone before testing might produce an artifactual situation. Not being allowed to drink for 1.5hrs also seems to skew things. Taken together it would be a bit like deliberately drying someone out. They did do a dose response study but frustratingly give no data on the results. They say some people had a response to just 120ml.
Click to expand...

It's a shame that the study doesn't say how many of the patients received fludrocortisone!
The dose-response study would also have been interesting.

However, not drinking anything for 1.5 hours does not seem to me to be the same as "deliberately drying someone out."
If a person drinks 3 liters in 15 hours of waking time, 200 ml at a time, that means they drink once an hour.
If they always drink 300 ml at a time, that means they drink every 1.5 hours.
And 3 liters is quite a lot.
Or did you mean, in connection with the dismissal of fludrocortisone? (of which we do not know how many patients received it)

If I understand the study correctly, drinking 480 ml of water led to higher blood pressure in almost all patients?

Also interesting:
"Water drinking causes a marked increase in blood pressure in a substantial proportion of patients with severe orthostatic hypotension due to autonomic failure. The increase in seated blood pressure after water drinking is apparent within 5 minutes, reaches a maximum after approximately 35 minutes, and is sustained for more than 60 minutes."
 
salin said:
Or did you mean, in connection with the dismissal of fludrocortisone?
Click to expand...

Yes, it was 'taken together with'.
The results with that time frame sound reasonably plausible. There ought to be a transient increase in blood volume developing over about 20-30 minutes and waning with peeing by about 45-60 minutes.
Although they do not give the dose response data the implication is that 120ml was less effective.

The interesting implication seems to be that there is no need to give fluid IV - that oral is effective, which is what one would expect. It also suggests that water is fine so no need for salt or saline. The only question is whether doing this on top of what people do anyway to keep themselves hydrated is worth the effort.
 
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