From the Guidelines
Treatment options for orthostatic hypotension include both non-pharmacological and pharmacological approaches, with the goal of reducing symptoms rather than normalizing blood pressure measurements. Non-pharmacological measures should be tried first, including:
- Increasing fluid intake to 2-3 liters daily
- Adding salt to the diet (8-10g/day)
- Wearing compression stockings that extend to the waist
- Performing physical countermaneuvers like leg crossing and muscle tensing when standing
- Elevating the head of the bed by 4-6 inches during sleep Patients should also avoid triggers such as hot environments, large meals, alcohol, and sudden position changes. If these measures are insufficient, medications can be added, with first-line pharmacological options including:
- Fludrocortisone (starting at 0.1mg daily, maximum 0.3mg daily), which enhances sodium retention and increases blood volume
- Midodrine (2.5-10mg three times daily), an alpha-1 agonist that increases peripheral vascular resistance Other medications include droxidopa (100-600mg three times daily), pyridostigmine (30-60mg three times daily), and occasionally low-dose ephedrine or methylphenidate, as recommended by the 2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope 1. These medications work by either expanding blood volume, increasing peripheral vasoconstriction, or enhancing sympathetic activity. Treatment should be individualized based on symptom severity, comorbidities, and underlying causes of orthostatic hypotension. The most recent and highest quality study, published in 2023, also supports the use of midodrine, droxidopa, and fludrocortisone for the treatment of orthostatic hypotension, with the addition of pyridostigmine as an option for patients who are refractory to other treatments 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 options for orthostatic hypotension include midodrine hydrochloride tablets, which are indicated for the treatment of symptomatic orthostatic hypotension. However, midodrine should 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 Midodrine should be continued only for patients who report significant symptomatic improvement 2.
From the Research
Treatment Options for Orthostatic Hypotension
The treatment goals for orthostatic hypotension are reducing symptoms and improving quality of life 3. Some of the treatment options include:
- Nonpharmacologic strategies:
- Dietary modifications
- Compression garments
- Physical maneuvers
- Avoiding environments that exacerbate symptoms
- Pharmacologic strategies:
Pharmacologic Treatment
Pharmacologic treatment for orthostatic hypotension includes:
- Midodrine: has similar efficacy to dihydroergotamine mesylate, norfenefrine, fludrocortisone, and etilefrine, and is more effective than dimetofrine and ephedrine in patients with orthostatic hypotension 4
- Fludrocortisone: its effects on blood pressure, orthostatic symptoms, or adverse events in people with orthostatic hypotension are uncertain 5
- Droxidopa: is a first-line medication for the treatment of orthostatic hypotension 3
Nonpharmacologic Treatment
Nonpharmacologic treatment for orthostatic hypotension includes:
- Increasing fluid and salt intake
- Venous compression methods
- Avoiding environments that exacerbate symptoms
- Physical maneuvers to improve blood flow and reduce symptoms
Special Considerations
Treatment of orthostatic hypotension in special situations, such as in hypertensive and hospitalized patients, requires careful consideration of the patient's underlying condition and medical history 6.