How to manage postural hypotension?

From the Guidelines

Postural hypotension can be effectively managed through a combination of non-pharmacological and pharmacological approaches, with the primary goal of minimizing postural symptoms and preventing complications such as syncope and falls. The management of postural hypotension should prioritize lifestyle modifications, including rising slowly from sitting or lying positions, staying well-hydrated with 2-3 liters of fluid daily, increasing salt intake (if not contraindicated by other conditions), avoiding alcohol, and wearing compression stockings that extend to the waist 1.

Some key non-pharmacological interventions include:

• Acute water ingestion, which can temporarily restore orthostatic tolerance in patients with neurogenic orthostatic hypotension (OH) 1
• Physical counter-pressure maneuvers, such as leg crossing, lower body muscle tensing, and maximal force handgrip, which can increase blood pressure and improve orthostatic symptoms 1
• Compression garments, which can improve orthostatic symptoms and blunt associated decreases in blood pressure in patients with OH, including older adult patients and those with neurogenic etiologies 1

If these measures are insufficient, pharmacological treatment should be considered. Midodrine, a peripheral selective α1-adrenergic agonist, is a first-line drug that exerts a pressor effect through both arteriolar constriction and venoconstriction of the capacitance vessels, and is the only medication approved by the Food and Drug Administration for the treatment of symptomatic orthostatic hypotension 1. The dosing of midodrine should be individually tailored, with a typical dose range of 2.5-10 mg three times daily, and the last dose should be taken before 6 PM to avoid supine hypertension. Other pharmacological options include fludrocortisone, which increases plasma volume and can improve symptoms of OH, and droxidopa, which can improve symptoms of neurogenic OH due to Parkinson disease, pure autonomic failure, and multiple system atrophy 1.

It is essential to weigh the potential risks of a drug against its possible benefit, including the balance between the goal of increasing standing blood pressure and the avoidance of a marked supine hypertension 1. The treatment of postural hypotension should be individualized, taking into account the underlying cause, severity of symptoms, and presence of comorbidities. Regular monitoring of blood pressure, symptoms, and potential side effects is crucial to optimize treatment and prevent complications.

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

To manage postural hypotension, midodrine can be used as it is indicated for the treatment of symptomatic orthostatic hypotension. However, it should only be used in patients whose lives are considerably impaired despite standard clinical care, including:

• Non-pharmacologic treatment (such as support stockings)
• Fluid expansion
• Lifestyle alterations 2 2

From the Research

Management of Postural Hypotension

To manage postural hypotension, several strategies can be employed, including:

• Removal of drugs that can worsen postural hypotension, such as tamsulosin, tizanidine, sildenafil, trazodone, and carvedilol 3
• Use of abdominal binders to prevent postural hypotension 3
• Administration of acarbose to prevent postprandial hypotension 3
• Harnessing residual sympathetic tone with atomoxetine, which blocks norepinephrine reuptake in nerve terminals 3
• Use of pyridostigmine, which facilitates cholinergic neurotransmission in autonomic ganglia 3
• Oral water bolus to acutely but transiently increase blood pressure in autonomic failure patients 3
• Use of traditional pressor agents, such as midodrine and droxidopa, at the lowest dose and frequency that improves symptoms 3
• Increasing fluid and salt intake 4
• Venous compression methods 4
• Use of fludrocortisone, a mineralocorticoid that increases blood volume and blood pressure, as a first- or second-line pharmacological therapy for orthostatic hypotension 4

Pharmacological Therapy

Pharmacological therapy for postural hypotension includes:

• Fludrocortisone, which has been shown to have very low-certainty evidence about its effects on drop in blood pressure and orthostatic symptoms in people with diabetes and Parkinson disease 4
• Pyridostigmine, which has been shown to have very low-certainty evidence about its effects on drop in blood pressure in people with Parkinson disease 4
• Domperidone, which has been shown to have very low-certainty evidence about its effects on orthostatic symptoms in people with Parkinson disease 4
• Midodrine and droxidopa, which can be used as traditional pressor agents 3

Non-Pharmacological Therapy

Non-pharmacological therapy for postural hypotension includes:

• Increasing fluid and salt intake 4
• Venous compression methods 4
• Abdominal binders to prevent postural hypotension 3
• Acarbose to prevent postprandial hypotension 3
• Oral water bolus to acutely but transiently increase blood pressure in autonomic failure patients 3