From the Guidelines
Postural hypotension can be effectively treated with a combination of non-pharmacological and pharmacological approaches, with the most recent and highest quality study recommending midodrine, droxidopa, and fludrocortisone as beneficial medications for patients with syncope due to neurogenic orthostatic hypotension 1.
Non-Pharmacological Approaches
- Rising slowly from sitting or lying positions
- Staying well-hydrated by drinking 2-3 liters of water daily
- Increasing salt intake (if not contraindicated by other conditions)
- Wearing compression stockings
- Avoiding alcohol and large meals
- Physical countermaneuvers like crossing legs when standing or squeezing a rubber ball to help maintain blood pressure
Pharmacological Approaches
- Midodrine (ProAmatine) at 2.5-10 mg three times daily (last dose before 6 PM to avoid supine hypertension) is an alpha-1 agonist that constricts blood vessels and can be beneficial in patients with syncope due to neurogenic OH 1.
- Droxidopa (Northera) at 100-600 mg three times daily increases norepinephrine levels and can be beneficial in patients with syncope due to neurogenic OH 1.
- Fludrocortisone (Florinef) at 0.1-0.3 mg daily increases sodium retention and blood volume and can be beneficial in patients with syncope due to neurogenic OH 1.
- Pyridostigmine (Mestinon) at 30-60 mg three times daily may help neurogenic orthostatic hypotension, as suggested by earlier studies 1. Regular monitoring of blood pressure in both lying and standing positions is essential to assess treatment effectiveness and adjust therapy as needed, with the most recent study providing guidance on the management of orthostatic hypotension 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
The treatment for postural hypotension is midodrine hydrochloride tablets, which are indicated for the treatment of symptomatic orthostatic hypotension (OH). However, it should be used in patients whose lives are considerably impaired despite standard clinical care, including non-pharmacologic treatment. Key considerations for treatment include:
- Non-pharmacologic treatment: such as support stockings, fluid expansion, and lifestyle alterations
- Patient selection: midodrine hydrochloride tablets should be used in patients whose lives are considerably impaired despite standard clinical care
- Monitoring: blood pressure should be monitored carefully when midodrine is used concomitantly with other agents that cause vasoconstriction 2
From the Research
Treatment Options for Postural Hypotension
- Non-pharmacological measures, such as optimizing blood volume, decreasing postural venous pooling, reducing heat and post-prandial induced vasodilation, emphasizing physical conditioning, and minimizing nocturnal diuresis, may be effective in treating postural hypotension 3
- Increasing fluid and salt intake, wearing compression garments, and using physical counter-maneuvers, such as leg crossing and leg muscle pumping, may also be beneficial 4
- Pharmacological interventions, such as fludrocortisone, midodrine, and pyridostigmine, may be used to treat postural hypotension, especially in cases where non-pharmacological measures are insufficient 5, 6, 7
Pharmacological Interventions
- Fludrocortisone, a mineralocorticoid, may increase blood volume and blood pressure, and is considered a first- or second-line pharmacological therapy for postural hypotension 5
- Midodrine, a prodrug that undergoes enzymatic hydrolysis to the selective alpha 1-adrenoceptor agonist desglymidodrine, may significantly increase standing systolic blood pressure and improve standing time and energy level 6
- Pyridostigmine, which enhances ganglionic transmission, may ameliorate postural hypotension without worsening supine hypertension, and may be used alone or in combination with midodrine 7
Non-Pharmacological Interventions
- Resistance exercises, electrical stimulation, and lower limb compression bandaging may not have a significant effect on postural hypotension, according to meta-analyses 4
- Physical maneuvers, such as leg crossing, leg muscle pumping, and bending forward, may improve postural hypotension, as may abdominal compression and sleeping with the head up 4
- Eating smaller, more frequent meals, and drinking water, may also be effective in treating postural hypotension 4