From the Guidelines
Treatment for orthostatic hypotension should prioritize non-pharmacological approaches, including increasing fluid intake to 2-3 liters daily and salt consumption to 8-10 grams per day, unless contraindicated, as well as physical countermeasures like standing up slowly and wearing compression stockings, as recommended by the most recent guidelines 1.
Non-Pharmacological Approaches
- Increase fluid intake to 2-3 liters daily and salt consumption to 8-10 grams per day, unless contraindicated by other conditions
- Physical countermeasures like standing up slowly, avoiding prolonged standing, performing isometric exercises, and wearing compression stockings can help maintain blood pressure
- Elevating the head of the bed by 4-6 inches reduces nocturnal diuresis and morning hypotension
Pharmacological Approaches
- Midodrine (ProAmatine) 2.5-10 mg three times daily is an alpha-1 agonist that increases vascular tone, but should be taken during waking hours only to avoid supine hypertension, as supported by studies 1
- Droxidopa (Northera) 100-600 mg three times daily can improve norepinephrine levels, and its use is recommended in patients with neurogenic orthostatic hypotension 1
- Pyridostigmine (Mestinon) 30-60 mg three times daily may benefit patients with neurogenic orthostatic hypotension, although its use is less commonly recommended 1
Special Considerations
- In patients with supine hypertension, non-pharmacological approaches should be prioritized, and BP-lowering medications that worsen orthostatic hypotension should be switched to alternative therapies 1
- Treatment should be tailored to the underlying cause and severity of symptoms, with careful monitoring for side effects like supine hypertension, as emphasized by recent guidelines 1
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
Treatment for orthostatic hypotension is midodrine hydrochloride tablets, but it should only be used in patients who have not responded to standard clinical care, including:
- Non-pharmacologic treatment (such as support stockings)
- Fluid expansion
- Lifestyle alterations It should be continued only for patients who report significant symptomatic improvement 2.
From the Research
Treatment Options for Orthostatic Hypotension
- Non-pharmacologic measures are often the first line of treatment, aiming to optimize blood volume, decrease postural venous pooling, and reduce heat and post-prandial induced vasodilation 3
- Pharmacologic measures, such as fludrocortisone, midodrine, and droxidopa, can be used to increase blood pressure and alleviate symptoms 4, 5, 6
- Treatment combinations, including mechanical and positional measures, can be effective in managing orthostatic hypotension 4, 7
Pharmacologic Treatment
- Fludrocortisone is a mineralocorticoid that increases blood volume and blood pressure, and is considered a first- or second-line pharmacological therapy for orthostatic hypotension 4
- Midodrine is a prodrug that increases standing systolic blood pressure, improves standing time and energy level, and reduces clinical symptoms of orthostatic hypotension 6
- Droxidopa is another pharmacologic agent that has been shown to increase blood pressure and alleviate symptoms of orthostatic hypotension 5
Non-Pharmacologic Treatment
- Discontinuing offending medications, switching medication administration to bedtime, avoiding large carbohydrate-rich meals, limiting alcohol, maintaining adequate hydration, and adding salt to diet are all non-pharmacologic strategies that can help manage orthostatic hypotension 3, 5
- Increasing fluid and salt intake, and using venous compression methods can also be effective in reducing symptoms of orthostatic hypotension 4
Considerations for Treatment
- Patient-specific factors, such as tolerability, adverse effects, and drug-drug and drug-disease interactions, should guide medication management of primary orthostatic hypotension 5
- The risk of supine hypertension, which is associated with midodrine therapy, can be reduced by taking the final daily dose at least 4 hours before bedtime 6