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 10-12 grams per day, unless contraindicated, as well as physical countermeasures like compression stockings and elevating the head of the bed, as recommended by the most recent guidelines 1.
Non-Pharmacological Approaches
- Increase fluid intake to 2-3 liters daily and salt consumption to 10-12 grams per day, unless contraindicated by other conditions
- Physical countermeasures like standing up slowly, performing leg muscle contractions before rising, and using 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 and not within 4 hours of bedtime to avoid supine hypertension, as supported by studies 1
- Droxidopa (Northera) 100-600 mg three times daily can be effective for neurogenic orthostatic hypotension, as approved by the FDA and recommended in recent guidelines 1
- Fludrocortisone (Florinef) 0.1-0.3 mg daily may be considered, but its use may be limited by supine hypertension and other side effects, as noted in earlier studies 1
Individualized Treatment
- Treatment should be individualized based on symptom severity, underlying causes, and comorbidities
- Regular monitoring of blood pressure in both supine and standing positions is essential to assess treatment efficacy and detect potential supine hypertension, a common side effect of these medications, as emphasized in 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: Midodrine hydrochloride tablets are indicated for the treatment of symptomatic orthostatic hypotension (OH). The treatment should be used in patients whose lives are considerably impaired despite standard clinical care.
- Key Considerations:
- Marked elevation of supine blood pressure
- Use in patients with considerable impairment despite standard care
- Non-pharmacologic treatments, such as support stockings and lifestyle alterations, should be considered before initiating midodrine therapy 2
From the Research
Treatment Options for Orthostatic Hypotension
- Non-pharmacological 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
- These measures may include increasing fluid and salt intake, wearing compression garments, and making lifestyle changes such as avoiding large meals and alcohol 4, 5
- Pharmacological interventions may be necessary for more severe cases, with medications such as midodrine, droxidopa, fludrocortisone, and pyridostigmine being commonly used 6, 5, 7
- Midodrine has been shown to be effective in increasing standing systolic blood pressure and improving symptoms of orthostatic hypotension, with a similar efficacy to other medications such as dihydroergotamine mesylate and fludrocortisone 7
- Fludrocortisone is a mineralocorticoid that increases blood volume and blood pressure, and is considered a first- or second-line pharmacological therapy for orthostatic hypotension 6
Non-Pharmacological Interventions
- Physical counter-maneuvers such as leg crossing, leg muscle pumping/contractions, and bending forward have been shown to improve orthostatic hypotension 4
- Abdominal compression and sleeping with the head tilted up have also been found to be effective in improving orthostatic hypotension 4
- Eating smaller, more frequent meals and drinking plenty of water may also help to alleviate symptoms 4
Pharmacological Interventions
- Midodrine is an effective therapeutic option for the management of orthostatic hypotension, with a well-tolerated side effect profile 7
- Fludrocortisone has been shown to have very low-certainty evidence for its effectiveness in treating orthostatic hypotension, but may be beneficial in certain patient populations 6
- Droxidopa and pyridostigmine are also commonly used medications for the treatment of orthostatic hypotension, although more research is needed to fully understand their effectiveness 5