From the Guidelines
Orthostatic hypotension is best managed through a combination of lifestyle modifications and medications, with the primary goal of improving standing blood pressure and reducing symptoms like dizziness and syncope. The management of orthostatic hypotension involves a multifaceted approach, including non-pharmacological and pharmacological interventions. Initial management includes increasing fluid intake to 2-3 liters daily and salt consumption to 8-10 grams per day, wearing compression stockings, performing physical countermaneuvers like leg crossing when standing, and avoiding rapid position changes 1.
Non-Pharmacological Interventions
- Increasing fluid intake to 2-3 liters daily
- Salt consumption to 8-10 grams per day
- Wearing compression stockings
- Performing physical countermaneuvers like leg crossing when standing
- Avoiding rapid position changes Medications may be necessary when these measures are insufficient.
Pharmacological Interventions
- First-line pharmacological options include midodrine (2.5-10 mg three times daily), which causes peripheral vasoconstriction, and fludrocortisone (0.1-0.3 mg daily), which increases sodium retention and blood volume 1.
- For refractory cases, droxidopa (100-600 mg three times daily) may be used 1.
- Pyridostigmine (30-60 mg three times daily) can help in neurogenic orthostatic hypotension 1. Patients should take medications during daytime hours and avoid evening doses to prevent supine hypertension. Underlying causes such as dehydration, anemia, or medication side effects should be addressed. Treatment aims to improve standing blood pressure and reduce symptoms like dizziness and syncope by maintaining adequate cerebral perfusion, rather than normalizing blood pressure readings 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 indication is based on midodrine's effect on increases in 1-minute standing systolic blood pressure, a surrogate marker considered likely to correspond to a clinical benefit. After initiation of treatment, midodrine hydrochloride tablets should be continued only for patients who report significant symptomatic improvement.
Management of Orthostatic Hypotension includes:
- Non-pharmacologic treatment, such as support stockings
- Fluid expansion
- Lifestyle alterations
- Pharmacologic treatment with midodrine hydrochloride tablets for patients whose lives are considerably impaired despite standard clinical care 2 It is essential to carefully evaluate and monitor patients for potential side effects, such as supine hypertension, and adjust treatment accordingly 2
From the Research
Management of Orthostatic Hypotension
The management of orthostatic hypotension (OH) involves a combination of nonpharmacological and pharmacological strategies.
- Nonpharmacological strategies include increasing fluid and salt intake, avoiding large carbohydrate-rich meals, limiting alcohol, maintaining adequate hydration, and adding salt to the diet 3, 4.
- Pharmacological strategies include the use of midodrine, droxidopa, fludrocortisone, pyridostigmine, and atomoxetine 5, 6, 4, 7.
Pharmacological Treatment
The choice of pharmacological treatment depends on the underlying cause of OH and the patient's specific needs.
- Midodrine and droxidopa are considered first-line treatments for OH, as they have been shown to increase blood pressure and alleviate symptoms 4, 7.
- Fludrocortisone is also used to treat OH, particularly in patients with diabetes or Parkinson's disease 5, 6.
- Pyridostigmine and atomoxetine may be used in patients who fail to respond to other treatments 6, 4.
Nonpharmacological Interventions
Nonpharmacological interventions can be used in conjunction with pharmacological treatments to manage OH.
- Increasing fluid and salt intake can help to increase blood volume and reduce symptoms of OH 3, 4.
- Avoiding large carbohydrate-rich meals and limiting alcohol can also help to reduce symptoms of OH 3, 4.
- Physical countermaneuvers, such as leg crossing and muscle tensing, can help to increase blood pressure and reduce symptoms of OH 5.
Special Considerations
The management of OH may need to be tailored to specific patient populations, such as the elderly or those with underlying medical conditions.