How to manage orthostatic hypotension in a patient with hypertension (HTN), peripheral vascular disease, chronic kidney disease, and gout, who is currently taking allopurinol?

From the Guidelines

Managing orthostatic hypotension in a patient with hypertension, peripheral vascular disease, chronic kidney disease, and gout requires a careful approach, and the most effective strategy is to recommend non-pharmacological interventions, including gradual position changes, adequate hydration, and compression stockings, as well as consider medication adjustments, such as midodrine or fludrocortisone, as stated in the 2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope 1. The patient's current medication, allopurinol, does not typically worsen orthostatic hypotension, so it can be continued for gout management. Key considerations in managing this patient include:

• Monitoring kidney function closely with any medication changes, as CKD increases sensitivity to medications
• Avoiding exacerbation of underlying conditions, such as hypertension and peripheral vascular disease
• Evaluating treatment effectiveness through blood pressure monitoring in various positions
• Considering the use of midodrine (2.5-10mg three times daily, with last dose at least 4 hours before bedtime) or fludrocortisone (0.1-0.2mg daily with monitoring for fluid retention) for persistent symptoms, as recommended in the 2017 ACC/AHA/HRS guideline 1
• Pursuing non-pharmacological approaches as the first-line treatment of orthostatic hypotension, as recommended in the 2024 ESC guidelines for the management of elevated blood pressure and hypertension 1. It is also important to note that the patient's lack of antihypertensive medication may actually be beneficial in this case, as reducing or modifying antihypertensive regimens can help alleviate orthostatic hypotension, as suggested in the 2024 ESC guidelines 1. Overall, a careful and individualized approach is necessary to manage orthostatic hypotension in this patient with multiple comorbidities.

From the Research

Management of Orthostatic Hypotension

To manage orthostatic hypotension in a patient with hypertension, peripheral vascular disease, chronic kidney disease, and gout, who is currently taking allopurinol, the following approaches can be considered:

• Nonpharmacologic strategies, such as dietary modifications, compression garments, physical maneuvers, and avoiding environments that exacerbate symptoms 2
• Initial treatment focuses on the underlying cause and adjusting potentially causative medications 2
• First-line medications include midodrine and droxidopa 2
• Fludrocortisone may also be considered, although it has concerning long-term effects 2, 3

Medication Options

• Midodrine is a prodrug that increases 1-minute standing systolic blood pressure and improves standing time and energy level, with common adverse events including piloerection, pruritus, and urinary retention 4
• Fludrocortisone is a mineralocorticoid that increases blood volume and blood pressure, but its effects on blood pressure, orthostatic symptoms, and adverse events are uncertain 3
• Droxidopa is another option, although its use is not as well-studied as midodrine and fludrocortisone 2, 5

Diagnosis and Treatment Approach

• Diagnosis of orthostatic hypotension requires careful history taking, physical examination, and supine and upright blood pressure measurements 6
• Management and prognosis vary according to the underlying cause, with the main distinction being whether orthostatic hypotension is neurogenic or non-neurogenic 6
• A stepwise, individualized, and primarily non-pharmacological approach to management is recommended, including cessation of blood pressure lowering drugs, lifestyle measures, and treatment with pharmacological agents in selected cases 6, 5