What are the treatment options for orthostatic hypotension?

From the Guidelines

Treatment for Orthostatic Hypotension Treatment for orthostatic hypotension typically involves a combination of lifestyle modifications and medications. Initially, patients are advised to increase salt and fluid intake, avoid standing for long periods, and rise slowly from a seated or lying position 1.

Lifestyle Modifications

• Increase salt and fluid intake to at least 2-3 L of fluids per day and 10 g of NaCl 1
• Avoid standing for long periods and rise slowly from a seated or lying position 1
• Use physical counter-pressure maneuvers such as leg crossing, squatting, and tensing muscles 1
• Wear compression stockings to help improve blood flow and reduce symptoms 1
• Sleep with the head of the bed elevated to prevent nocturnal polyuria and maintain a more favorable distribution of body fluids 1

Medications

• Midodrine: a peripheral selective α1-adrenergic agonist that exerts a pressor effect through both arteriolar constriction and venoconstriction of the capacitance vessels, dosing should be individually tailored (up to two to four times 10 mg/day) 1
• Fludrocortisone: a mineralocorticoid that acts through sodium retention, a direct constricting effect on partially denervated vessels, and an increase in the water content of the vessel wall leading to a reduced distensibility, initial dose should be 0.05–0.1 mg daily with individual titration to 0.1–0.3 mg daily 1
• Pyridostigmine: may be beneficial in patients with syncope due to neurogenic OH who are refractory to other treatments, dosing is 30-60 mg, 2-3 times daily 1
• Droxidopa: may be beneficial in patients with syncope due to neurogenic OH, dosing and titration should be individualized 1

It is essential to monitor blood pressure regularly and adjust treatment as needed to avoid complications. In some cases, patients may require hospitalization to manage severe orthostatic hypotension. It is crucial to work closely with a healthcare provider to determine the best course of treatment, as individual needs may vary 1. Regular follow-up appointments are necessary to assess the effectiveness of treatment and make any necessary adjustments.

From the FDA Drug Label

Midodrine hydrochloride tablets are indicated for the treatment of symptomatic orthostatic hypotension (OH) Because midodrine hydrochloride tablets can cause marked elevation of supine blood pressure (BP>200 mmHg systolic), it should be used in patients whose lives are considerably impaired despite standard clinical care, including non-pharmacologic treatment (such as support stockings), fluid expansion, and lifestyle alterations

The treatment options for orthostatic hypotension include:

• Midodrine hydrochloride tablets: indicated for the treatment of symptomatic orthostatic hypotension
• Non-pharmacologic treatment: such as
  • Support stockings
  • Fluid expansion
  • Lifestyle alterations 2

From the Research

Treatment Options for Orthostatic Hypotension

The treatment of orthostatic hypotension (OH) involves a combination of non-pharmacologic and pharmacologic measures. The goal of treatment is to improve symptoms, increase standing time, and enhance the quality of life 3, 4, 5, 6, 7.

Non-Pharmacologic Measures

Non-pharmacologic measures are often the first line of treatment for OH and may include:

• Reviewing and modifying medications that may exacerbate OH 3, 4, 7
• Increasing fluid and salt intake to optimize blood volume 3, 5
• Avoiding dehydration and blood loss 5, 7
• Elevating the head of the bed to reduce nocturnal diuresis 3, 6
• Using physical countermaneuvers, such as leg crossing and ankle contraction, to increase blood pressure 4, 7
• Avoiding prolonged standing and taking regular breaks to sit or lie down 3, 5

Pharmacologic Measures

Pharmacologic measures may be necessary for patients with severe OH or those who do not respond to non-pharmacologic measures. Medications that may be used to treat OH include:

• Fludrocortisone, a mineralocorticoid that helps increase blood volume 4, 5, 6, 7
• Midodrine, an alpha-adrenergic agonist that helps increase blood pressure 4, 5, 7
• Pyridostigmine, a cholinesterase inhibitor that helps increase blood pressure 7
• Droxidopa, a norepinephrine precursor that helps increase blood pressure 4

Treatment Approach

The treatment approach for OH typically involves a stepwise approach, starting with non-pharmacologic measures and adding pharmacologic measures as needed 3, 4, 7. The goal of treatment is to improve symptoms, increase standing time, and enhance the quality of life, while minimizing the risk of supine hypertension 4, 5, 7.