How is postural hypotension managed?

From the Guidelines

Postural hypotension is best managed through a combination of lifestyle modifications and medications, with the primary goal of minimizing postural symptoms rather than restoring normotension, as recommended by the most recent guidelines 1.

Management Strategies

The management of postural hypotension involves:

• Non-pharmacological measures such as ensuring adequate salt intake, avoiding medications that aggravate hypotension, using compressive garments over the legs and abdomen, and physical activity to avoid deconditioning 1.
• Pharmacologic measures, including midodrine and droxidopa, which are approved by the FDA for the treatment of orthostatic hypotension 1.

Lifestyle Modifications

Patients should be advised to:

• Rise slowly from sitting or lying positions
• Stay adequately hydrated with 2-3 liters of fluid daily
• Increase salt intake if not contraindicated by other conditions
• Wear compression stockings
• Avoid alcohol
• Elevate the head of the bed by 4-6 inches when sleeping

Medications

If lifestyle modifications are insufficient, medications may be necessary, including:

• Midodrine (2.5-10 mg three times daily, with the last dose at least 4 hours before bedtime) to increase vascular tone 1
• Droxidopa (100-600 mg three times daily) to raise blood pressure by converting to norepinephrine 1
• Fludrocortisone (starting at 0.1 mg daily) to increase blood volume by promoting sodium retention 1

Key Considerations

• The therapeutic goal is to minimize postural symptoms rather than to restore normotension 1.
• Supine blood pressure tends to be much higher in these patients, often requiring treatment of blood pressure at bedtime with shorter-acting drugs 1.
• Physical activity and exercise should be encouraged to avoid deconditioning, which is known to exacerbate orthostatic intolerance 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

Management of Postural Hypotension:

• Midodrine is used to treat symptomatic orthostatic hypotension.
• Non-pharmacologic treatments such as support stockings, fluid expansion, and lifestyle alterations should be tried first.
• Midodrine should only be used in patients whose lives are considerably impaired despite standard clinical care. 2

From the Research

Management of Postural Hypotension

The management of postural hypotension involves a combination of non-pharmacologic and pharmacologic measures.

• Non-pharmacologic measures include increasing fluid and salt intake, venous compression methods, and physical countermaneuvers 3, 4, 5.
• Pharmacologic measures include the use of fludrocortisone, midodrine, and droxidopa 3, 4, 6, 5.
• The goal of treatment is to improve symptoms and functional status, and not to target arbitrary blood pressure values 4.

Treatment Approach

The treatment approach for postural hypotension should be individualized and based on the underlying cause of the condition.

• For patients with mild symptoms, non-pharmacologic measures may be sufficient 3, 4.
• For patients with more severe symptoms, pharmacologic measures may be necessary 3, 4, 6, 5.
• The use of fludrocortisone, a mineralocorticoid, has been shown to be effective in increasing blood volume and blood pressure in patients with postural hypotension 6.

Monitoring and Education

Patient education and monitoring are important aspects of managing postural hypotension.

• Patients should be educated on the importance of increasing fluid and salt intake, and on how to perform physical countermaneuvers to improve orthostatic defenses 4, 5.
• Regular monitoring of blood pressure and symptoms is necessary to adjust treatment as needed 3, 4.
• A functional classification based on severity of symptoms is useful in monitoring the patient's condition and documenting improvement with treatment 3.