From the Guidelines
For patients with neurogenic orthostatic hypotension who also require treatment for hypertension, it's best to avoid vasodilating antihypertensives such as alpha-blockers, nitrates, diuretics, and ACE inhibitors/ARBs as these can worsen orthostatic symptoms, as recommended by the most recent guidelines 1. When managing hypertension in patients with neurogenic orthostatic hypotension, it's crucial to consider the potential impact of antihypertensive medications on orthostatic symptoms.
- Medications to avoid include:
- Alpha-blockers (doxazosin, prazosin)
- Nitrates
- Diuretics
- ACE inhibitors/ARBs These medications can exacerbate orthostatic hypotension, leading to increased morbidity and mortality.
- Preferred antihypertensive medications in this population include:
- Clonidine, which acts centrally to reduce sympathetic outflow without significantly affecting peripheral vascular tone when supine, as noted in 1
- Beta-blockers, which may be considered as an alternative but should be used cautiously
- Guanfacine, shorter-acting calcium blockers (e.g., isradipine), or shorter-acting β-blockers such as atenolol or metoprolol tartrate, as mentioned in 1 Non-pharmacological approaches should also be emphasized, including:
- Elevating the head of the bed at night to reduce supine hypertension
- Compression garments
- Increased salt and fluid intake
- Physical countermaneuvers when standing, as recommended in 1 and 1 It's essential to focus on controlling supine hypertension without exacerbating orthostatic symptoms, often accepting higher than normal supine blood pressures, as highlighted in 1 and 1.
From the FDA Drug Label
Midodrine should be used with caution in orthostatic hypotensive patients who are also diabetic, as well as those with a history of visual problems who are also taking fludrocortisone acetate, which is known to cause an increase in intraocular pressure and glaucoma. The risk of hypertension increases with concomitant administration of drugs that increase blood pressure (phenylephrine, pseudoephedrine, ephedrine, dihydroergotamine, thyroid hormones or droxidopa). Avoid concomitant use of drugs that increase blood pressure. If concomitant use cannot be avoided, monitor blood pressure closely Alpha-adrenergic blocking agents, such as prazosin, terazosin, and doxazosin, can antagonize the effects of midodrine
HTN meds to avoid in neurogenic orthostatic hypotension:
- Drugs that increase blood pressure, such as:
- Phenylephrine
- Pseudoephedrine
- Ephedrine
- Dihydroergotamine
- Thyroid hormones
- Droxidopa
- Alpha-adrenergic blocking agents, such as:
- Prazosin
- Terazosin
- Doxazosin Preferred med:
- Midodrine, with caution in certain patient populations, such as those with diabetes or visual problems, and with monitoring of blood pressure 2, 2, 2
From the Research
HTN Medications to Avoid in Neurogenic Orthostatic Hypotension
- Vasodilators and β-blockers can exacerbate neurogenic orthostatic hypotension (nOH) and concomitant symptoms 3
- Medications that can worsen supine hypertension, such as fludrocortisone, should be used with caution in patients with nOH 4
Preferred Medications for Neurogenic Orthostatic Hypotension
- Midodrine, an alpha-1 agonist, has been shown to be effective in increasing standing blood pressure and decreasing orthostatic symptoms in patients with nOH 5, 4, 6
- Droxidopa, a synthetic amino acid converted to norepinephrine, has been approved for the treatment of neurogenic OH associated with primary autonomic neuropathies, including Parkinson's disease, multiple system atrophy, and pure autonomic failure 3, 6
- Other medications, such as octreotide, indomethacin, and ergotamine, may also be effective in elevating standing blood pressure and/or orthostatic tolerance, but more research is needed to confirm their efficacy 4