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Orthostatic Intolerance

OI is common in ME/CFS; screen with history and simple office maneuvers and treat with conservative measures first.

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Screen

History cues and quick office checks to surface OI.

  • Ask about lightheadedness, palpitations, presyncope, ‘pressure’, and heat/shower/standing intolerance.
  • Perform lying→standing vitals at 0, 2, 5, 10 minutes; document symptoms.
Quick questions
  • Worse upright, better supine?
  • Palpitations, lightheadedness, presyncope, “head pressure”?
  • Intolerance of heat, showers, or prolonged standing?

10-Minute Stand (NASA Lean Test)

Simple in-clinic protocol; stop early for presyncope.

  1. 10-minute stand (NASA Lean Test): supine rest 10 min → record HR/BP; stand with back/shoulders lightly against wall (heels ~6 inches out); record HR/BP at 2/5/10 min with symptoms.
Document
  • HR & BP at 0 / 2 / 5 / 10 minutes
  • Symptoms (dizziness, pressure, brain fog, palpitations)
  • Any need to abort test; safety considerations

Management

Start conservative; add meds when needed. Avoid provoking PEM.

First-line (low risk)
  • First-line: ~2–3 L fluids/day as tolerated; liberalize salt if safe; waist-high compression.
If insufficient / as appropriate
  • Consider medications when conservative measures are insufficient (e.g., fludrocortisone, midodrine, beta-blocker, pyridostigmine).
  • Pyridostigmine (start low; often 30–60 mg/day divided; titrate as tolerated)
Pro tips
  • Pair all changes with pacing; monitor for PEM.
  • Compression: waist-high 20–30 mmHg if tolerated.
  • “Start low, go slow”; reassess in 4–6 weeks.

For health professionals. Informational only — not medical advice. Based on IOM/NAM 2015 criteria and common clinical practices.