From the Guidelines
To properly manage orthostatic hypotension, a combination of nonpharmacologic measures, such as ensuring adequate salt intake, avoiding medications that aggravate hypotension, and using compressive garments over the legs and abdomen, should be implemented, along with pharmacologic measures like midodrine or droxidopa, as recommended by the most recent guidelines 1. The therapeutic goal is to minimize postural symptoms rather than to restore normotension.
- Nonpharmacologic measures include:
- Ensuring adequate salt intake
- Avoiding medications that aggravate hypotension
- Using compressive garments over the legs and abdomen
- Encouraging physical activity and exercise to avoid deconditioning
- Volume repletion with fluids and salt
- Pharmacologic measures include:
- Midodrine, a peripheral selective α1-adrenergic agonist, which is a first-line drug for the treatment of orthostatic hypotension 1
- Droxidopa, which improves symptoms of neurogenic orthostatic hypotension due to Parkinson disease, pure autonomic failure, and multiple system atrophy 1
- Other possible treatments, such as fludrocortisone, pyridostigmine, and octreotide, may be beneficial in selected patients, but their use should be individualized and monitored closely 1. It is essential to weigh the potential risks of a drug against its possible benefit, including the balance between the goal of increasing standing blood pressure and the avoidance of a marked supine hypertension.
- The dosing of midodrine should be individually tailored, up to two to four times 10 mg/day, with the first dose taken before arising and use avoided several hours before planned recumbency, particularly in patients with documented supine hypertension 1.
- The use of droxidopa may be limited by supine hypertension, headache, dizziness, and nausea, and its effectiveness may be decreased by the use of carbidopa in patients with Parkinson disease 1.
From the FDA Drug Label
The recommended dose of midodrine hydrochloride tablets is 10 mg, 3 times daily. Dosing should take place during the daytime hours when the patient needs to be upright, pursuing the activities of daily living A suggested dosing schedule of approximately 4-hour intervals is as follows: shortly before, or upon arising in the morning, midday and late afternoon (not later than 6 P.M.) In order to reduce the potential for supine hypertension during sleep, midodrine hydrochloride tablets should not be given after the evening meal or less than 4 hours before bedtime.
The proper way to take Orthostatics (midodrine) is:
- 10 mg, 3 times daily
- During daytime hours when the patient is upright and pursuing daily activities
- At 4-hour intervals, such as:
- Shortly before or upon arising in the morning
- Midday
- Late afternoon (not later than 6 P.M.)
- Not after the evening meal or less than 4 hours before bedtime 2
From the Research
Orthostatic Hypotension Treatment
The proper way to take orthostatics, or rather, manage orthostatic hypotension, involves a combination of non-pharmacologic and pharmacologic strategies.
- Non-pharmacologic strategies include dietary modifications, compression garments, physical maneuvers, and avoiding environments that exacerbate symptoms 3, 4.
- Pharmacologic strategies include the use of midodrine, droxidopa, and fludrocortisone 3, 4, 5.
Medication Management
When it comes to medication management, the goal is to improve standing blood pressure and minimize symptoms without generating excessive supine hypertension 4.
- Midodrine and droxidopa are considered first-line medications for orthostatic hypotension 3.
- Fludrocortisone is also used, but its long-term effects are concerning 3, 5.
- The evidence for the effectiveness of these medications is limited, and more research is needed to determine their long-term benefits and risks 5, 6.
Treatment Persistence
Treatment persistence is a significant issue in orthostatic hypotension management, with patients often discontinuing treatment after a short period 7.