From the Guidelines
Management of orthostatic intolerance should prioritize non-pharmacological approaches, including lifestyle modifications such as adequate hydration with 2-3 liters of fluid daily, increased salt intake (5-10g/day), and compression garments for the lower extremities, as recommended by the most recent study 1.
Non-Pharmacological Approaches
- Lifestyle modifications:
- Adequate hydration with 2-3 liters of fluid daily
- Increased salt intake (5-10g/day)
- Compression garments for the lower extremities
- Gradual positional changes when moving from lying to standing
- Physical countermaneuvers:
- Leg crossing
- Muscle tensing
- Regular exercise focusing on lower extremity strength
Pharmacological Approaches
- Fludrocortisone (starting at 0.1mg daily, maximum 0.2mg daily) is recommended to increase sodium retention and blood volume, as supported by the 2022 study 1.
- Midodrine, an alpha-1 agonist, can be used at 2.5-10mg three times daily (avoiding evening doses to prevent supine hypertension)
- Beta-blockers like propranolol (10-20mg twice daily) may benefit patients with hyperadrenergic symptoms
- Ivabradine (2.5-7.5mg twice daily) may help control heart rate in patients with POTS (Postural Orthostatic Tachycardia Syndrome)
Additional Considerations
- Treatment should be individualized based on the specific type of orthostatic intolerance and underlying pathophysiology
- Regular monitoring for medication side effects and efficacy is crucial
- The goal of therapy is to improve orthostatic tolerance by enhancing venous return, increasing blood volume, and modulating autonomic nervous system function, as emphasized by the 2017 study 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 management options for Orthostatic Intolerance include:
- Midodrine: a medication that can help increase blood pressure and reduce symptoms of orthostatic hypotension
- Non-pharmacologic treatment: such as
- Support stockings
- Fluid expansion
- Lifestyle alterations It is essential to carefully evaluate the potential for supine and sitting hypertension when initiating midodrine therapy, and to monitor blood pressure closely, especially when used concomitantly with other agents that cause vasoconstriction 2 2.
From the Research
Management Options for Orthostatic Intolerance
The management of Orthostatic Intolerance (OI) involves a combination of non-pharmacological and pharmacological interventions.
- Non-pharmacological interventions: These include increasing fluid and salt intake, wearing compression garments, performing physical counter-maneuvers such as leg crossing and leg muscle pumping, and eating smaller, more frequent meals 3.
- Lifestyle modifications: Sleeping with the head tilted up, avoiding large meals, and avoiding standing for long periods can also help manage OI symptoms 4.
- Pharmacological interventions: Medications such as fludrocortisone, midodrine, pyridostigmine, and droxidopa can be used to treat OI, particularly in cases of orthostatic hypotension 5, 6.
- Specific treatments: For postural orthostatic tachycardia syndrome, non-pharmacological interventions such as increasing fluid and salt intake, wearing compression garments, and performing physical counter-maneuvers may be effective 7.
- Individualized approach: The management of OI should be individualized, taking into account the patient's underlying condition, symptoms, and response to treatment 3, 5.
Treatment of Orthostatic Hypotension
Orthostatic hypotension (OH) is a common symptom of OI, and its treatment involves a combination of non-pharmacological and pharmacological interventions.
- Non-pharmacological interventions: Increasing fluid and salt intake, wearing compression garments, and performing physical counter-maneuvers can help manage OH symptoms 3.
- Pharmacological interventions: Medications such as fludrocortisone, midodrine, pyridostigmine, and droxidopa can be used to treat OH, particularly in cases of neurogenic OH 5, 6.
- Supine hypertension and postprandial hypotension: These conditions can exacerbate OH and should be managed accordingly 5.
Future Research Directions
Further research is needed to fully understand the pathophysiology of OI and to develop effective treatments.
- Non-pharmacological interventions: More studies are needed to evaluate the effectiveness of non-pharmacological interventions for OI, particularly in children and adults with postural orthostatic tachycardia syndrome 7.
- Pharmacological interventions: More studies are needed to evaluate the effectiveness and safety of pharmacological interventions for OI, particularly in cases of orthostatic hypotension 6.