From the Guidelines
To improve hypotension in elderly patients, it is crucial to prioritize non-pharmacological approaches as the first-line treatment, especially for those with supine hypertension, as recommended by the 2024 ESC guidelines 1. When managing hypotension in the elderly, it's essential to consider the patient's overall health status, including the presence of orthostatic hypotension.
- Identifying and addressing the underlying cause of hypotension is vital, and this may involve reviewing and adjusting medications that could be contributing to the condition, such as antihypertensives, diuretics, antidepressants, and alpha-blockers.
- Non-pharmacological interventions include ensuring adequate hydration, gradual position changes, wearing compression stockings, increasing salt intake if appropriate, and performing isometric exercises before standing, as these measures can help increase blood volume and enhance vascular tone.
- According to the 2024 ESC guidelines, before starting or intensifying BP-lowering medication, it is recommended to test for orthostatic hypotension by measuring BP after standing 1.
- For patients with supine hypertension, switching BP-lowering medications that worsen orthostatic hypotension to an alternative therapy is recommended, rather than simply de-intensifying treatment 1.
- Pharmacological interventions, such as midodrine, fludrocortisone, droxidopa, or pyridostigmine, may be considered in certain cases, but their use should be guided by the individual patient's needs and response to treatment.
- In cases of acute hypotension, intravenous fluids and vasopressors may be necessary to rapidly restore blood pressure and maintain adequate perfusion of vital organs.
From the FDA Drug Label
To be eligible for enrollment, patients were required to have a decrease in systolic or diastolic blood pressure of at least 20 or 10 mm Hg, respectively, within 3 minutes after standing. The study was enriched, such that only patients who had been identified as “responders” during the titration period were randomized to droxidopa or placebo To be considered a responder, a patient had to demonstrate improvement on the OHSA Item #1 score by at least 1 point, as well as an increase in systolic blood pressure of at least 10 mm Hg post-standing, during the open-label dose titration period Elevations in Blood Pressure Counsel patients that droxidopa causes elevations in blood pressure and increases the risk of supine hypertension, which could lead to strokes, heart attacks, and death Instruct patients to rest and sleep in an upper-body elevated position and monitor blood pressure Instruct patients how to manage observed blood pressure elevations.
The answer to improving hypotension in the elderly is to consider using droxidopa, which has been shown to increase systolic blood pressure by at least 10 mm Hg post-standing in responders. However, it is crucial to monitor blood pressure and instruct patients on how to manage observed blood pressure elevations to reduce the risk of supine hypertension. Patients should rest and sleep in an upper-body elevated position and take the late afternoon dose of droxidopa at least three hours before bedtime 2.
From the Research
Non-Pharmacological Strategies
- Avoiding large carbohydrate-rich meals 3, 4, 5
- Limiting alcohol consumption 3, 5
- Maintaining adequate hydration 3, 4, 5
- Adding salt to foods 3, 5
- Using compression stockings 3, 4, 6, 7
- Tilt-table exercises or abdominal binders 3
- Physical counter-maneuvers such as leg crossing, leg muscle pumping/contractions, and bending forward 4
- Sleeping with head tilted up 4
- Eating smaller, more frequent meals 4
- Drinking 480 mL of water to increase blood pressure 4
Pharmacological Interventions
- Fludrocortisone 3, 5
- Midodrine 3, 5, 7
- Pyridostigmine 3, 5, 7
- Droxidopa 5
- Atomoxetine 3, 5
- Sympathomimetic agents 5
- Octreotide 5
- Pseudoephedrine 3, 5