What are the management options for orthostatic hypotension?

From the Guidelines

Management of orthostatic hypotension should prioritize non-pharmacological approaches, including lifestyle modifications and physical counter-pressure maneuvers, with pharmacological interventions added as needed to reduce morbidity, mortality, and improve quality of life. The initial approach to managing orthostatic hypotension involves lifestyle modifications, such as adequate hydration, increasing salt intake, wearing compression garments, and performing physical counter-pressure maneuvers like leg crossing or squatting when feeling dizzy 1.

Key Non-Pharmacological Interventions:

• Adequate hydration: Encouraging increased fluid intake, with a focus on water ingestion, which can temporarily restore orthostatic tolerance 1.
• Increased salt intake: Salt supplementation may improve blood pressure and decrease symptoms from orthostatic hypotension, although this should be approached with caution in patients with hypertension, renal disease, or cardiac dysfunction 1.
• Compression garments: Wearing thigh-high or abdominal compression garments can improve orthostatic symptoms and blunt associated decreases in blood pressure 1.
• Physical counter-pressure maneuvers: Techniques like leg crossing, lower body muscle tensing, and maximal force handgrip can increase blood pressure, with squatting being particularly effective 1.

Pharmacological Interventions:

If non-pharmacological measures are insufficient, medications can be considered.

• Midodrine is recommended as a first-line pharmacological option for patients with neurogenic orthostatic hypotension, given its ability to improve symptoms of orthostatic hypotension by increasing standing blood pressure, although its use may be limited by supine hypertension and other side effects 1.
• Droxidopa can also be beneficial, particularly in patients with neurogenic orthostatic hypotension due to conditions like Parkinson's disease, pure autonomic failure, and multiple system atrophy, as it improves symptoms and may reduce falls 1.
• Fludrocortisone, which increases plasma volume and improves symptoms of orthostatic hypotension, can be considered, although its use may be limited by supine hypertension and other side effects like edema and hypokalemia 1.
• Other medications, including pyridostigmine and octreotide, may be beneficial in specific cases, such as refractory neurogenic orthostatic hypotension or postprandial orthostatic hypotension, respectively 1. The goal of treatment should be to reduce falls, improve quality of life, and manage symptoms rather than targeting specific blood pressure numbers, while also monitoring for and managing potential side effects like supine hypertension.

From the FDA Drug Label

Studies 301 and 306B showed a treatment effect of droxidopa at Week 1, but none of the studies demonstrated continued efficacy beyond 2 weeks of treatment Efficacy was measured using the OHSA Item #1 score (“dizziness, lightheadedness, feeling faint, and feeling like you might black out”) at Week 1, in patients who had completed titration and 1 week of maintenance therapy. Patients receiving droxidopa also had a greater increase, compared to placebo, in the Week 1 lowest standing systolic blood pressure within 3 minutes after standing (5.6 mm Hg; P=0. 032).

The management options for orthostatic hypotension include droxidopa.

• Droxidopa has shown a treatment effect at Week 1, with a mean 0.9 unit decrease in dizziness and a 5.6 mm Hg increase in lowest standing systolic blood pressure within 3 minutes after standing.
• However, the effectiveness of droxidopa beyond 2 weeks is uncertain, and patients should be evaluated periodically to determine whether droxidopa is continuing to provide a benefit 2.

From the Research

Management Options for Orthostatic Hypotension

• The management of orthostatic hypotension (OH) involves a combination of non-pharmacologic and pharmacologic measures, with the goal of reducing symptoms and improving quality of life 3, 4.
• Non-pharmacologic measures include:
  • Reviewing and modifying medications that may aggravate or cause OH 3
  • Increasing fluid and salt intake 4, 5
  • Using compression garments 4, 6, 5
  • Physical maneuvers such as leg crossing, leg muscle pumping/contractions, and bending forward 5
  • Abdominal compression 5
  • Sleeping with head tilted up 5
  • Eating smaller, more frequent meals 5
  • Drinking water to increase blood pressure 5
• Pharmacologic measures include:
  • Midodrine, an alpha-1 adrenergic agonist, which is licensed for the pharmacological management of OH in the UK 6
  • Droxidopa, which is a first-line medication for OH 4
  • Fludrocortisone, which is a mineralocorticoid that increases blood volume and blood pressure, but has concerning long-term effects 4, 7

Classification and Diagnosis of Orthostatic Hypotension

• OH is classified as neurogenic or nonneurogenic, depending on etiology and heart rate response 4
• Diagnosis is confirmed by performing a bedside simplified Schellong test, which consists of blood pressure and heart rate measurements after five minutes in the supine position and three minutes after moving to a standing position 4
• If the patient is unable to stand safely or the clinical suspicion for OH is high despite normal findings on the bedside test, head-up tilt table testing is recommended 4

Prevalence and Risk Factors of Orthostatic Hypotension

• The prevalence of OH in the community setting is 20% in older adults and 5% in middle-aged adults 4
• Risk factors for OH include diabetes mellitus, which increases the prevalence of OH in all age groups 4
• OH is associated with a significant increase in cardiovascular risk and falls, and up to a 50% increase in relative risk of all-cause mortality 4