What is orthostatic hypotension and how is it managed?

From the Guidelines

Orthostatic hypotension is defined as a BP drop of ≥20/10 mmHg 1 and/or 3 min after standing following a 5-min period in the seated or lying position, as stated in the 2024 ESC guidelines for the management of elevated blood pressure and hypertension 1. This condition occurs when the body's compensatory mechanisms fail to maintain adequate blood pressure during positional changes, resulting in symptoms like dizziness, lightheadedness, blurred vision, weakness, and occasionally fainting.

Key Points to Consider:

• Management begins with non-pharmacological approaches including:
  • Gradual position changes
  • Adequate hydration (2-3 liters of fluid daily)
  • Increased salt intake (8-10g daily unless contraindicated)
  • Compression stockings
  • Avoiding triggers like hot environments, large meals, and alcohol
• Medications that may worsen symptoms should be adjusted when possible
• If these measures are insufficient, pharmacological treatment options include:
  • Fludrocortisone (starting at 0.1mg daily, maximum 0.3mg daily)
  • Midodrine (2.5-10mg three times daily)
  • Droxidopa (100-600mg three times daily)
  • Occasionally pyridostigmine (30-60mg three times daily)

Diagnosis and Monitoring:

• Diagnosis is made in the office, with routine ABPM not currently suitable for formally assessing orthostatic hypotension, though it may help in some cases, particularly when accompanied by a patient symptom diary 1
• Regular monitoring of blood pressure in different positions is essential to assess treatment effectiveness and adjust therapy accordingly

Treatment Goals:

• The goal of treatment is to minimize postural symptoms rather than to restore normotension, as stated in the guidelines for the diagnosis and management of syncope (version 2009) 1
• Treatment should be individualized, taking into account the patient's specific needs and medical history, with a focus on improving quality of life and reducing morbidity and mortality.

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

Orthostatic Hypotension (OH) is a condition where a patient experiences a significant drop in blood pressure when standing up from a sitting or lying down position. The management of OH includes:

• Non-pharmacologic treatment: such as support stockings, fluid expansion, and lifestyle alterations
• Pharmacologic treatment: such as midodrine hydrochloride tablets, which can help increase blood pressure and alleviate symptoms of OH It is essential to carefully evaluate and monitor patients with OH, especially when using medications like midodrine, to minimize the risk of supine hypertension and other potential side effects 2.

From the Research

Definition and Diagnosis of Orthostatic Hypotension

• Orthostatic hypotension (OH) is defined by a drop in arterial blood pressure (BP) of at least 20 mmHg for systolic BP and 10 mmHg for diastolic BP after standing 3, 4.
• Symptoms of OH are generally quite typical, but may also be rather vague, and diagnosis may be easily made by a physician in their office, and confirmed by more sophisticated measurements if necessary 3.
• Pathophysiology of OH is generally rather complex, but mostly involves a defect in the autonomic nervous system, in its sympathetic component, with failure of peripheral vasoconstriction playing a more important role than the defect in reflex tachycardia 3.

Management of Orthostatic Hypotension

• Treatment of OH always requires education of the patient regarding triggering situations and physiological countermanoeuvers 4.
• Pharmacological treatment may sometimes be necessary and mainly relies on volume expansion by fludrocortisone and/or a vasopressor agent such as midodrine 4, 5, 6.
• Nonpharmacological strategies are the primary treatment, such as discontinuing offending medications, switching medication administration to bedtime, avoiding large carbohydrate-rich meals, limiting alcohol, maintaining adequate hydration, adding salt to diet, and so on 6.
• Midodrine and droxidopa possess the most evidence with respect to increasing blood pressure and alleviating symptoms, while pyridostigmine and fludrocortisone can be used in patients who fail to respond to these agents 6, 7.

Treatment Options

• Fludrocortisone is a mineralocorticoid that increases blood volume and blood pressure, and is considered the first- or second-line pharmacological therapy for OH alongside mechanical and positional measures 5.
• Midodrine and pyridostigmine can be used alone or in combination to treat OH, with midodrine being better than pyridostigmine at improving OH-related symptoms 7.
• Emerging evidence with low-dose atomoxetine is promising, especially in those with central autonomic failure, and may prove to be a viable alternative treatment option 6.