What are the medications used to manage hypotension?

From the Guidelines

Medications used to manage hypotension include midodrine, droxidopa, and fludrocortisone, among others, with the goal of minimizing postural symptoms rather than restoring normotension. When managing hypotension, it is crucial to consider the underlying cause and address it accordingly. For chronic orthostatic hypotension, midodrine (2.5-10 mg three times daily) and fludrocortisone (0.1-0.3 mg daily) are often prescribed 1. Droxidopa (100-600 mg three times daily) is another option for neurogenic orthostatic hypotension 1. Some key points to consider when treating hypotension include:

• Nonpharmacologic measures such as ensuring adequate salt intake, avoiding medications that aggravate hypotension, and using compressive garments over the legs and abdomen 1
• Pharmacologic measures such as midodrine, droxidopa, and fludrocortisone 1
• The importance of physical activity and exercise to avoid deconditioning, which can exacerbate orthostatic intolerance 1
• Volume repletion with fluids and salt is critical in managing hypotension 1
• The therapeutic goal is to minimize postural symptoms rather than to restore normotension 1

From the FDA Drug Label

Midodrine hydrochloride tablets are indicated for the treatment of symptomatic orthostatic hypotension (OH) Give this solution by intravenous infusion. Insert a plastic intravenous catheter through a suitable bore needle well advanced centrally into the vein and securely fixed with adhesive tape, avoiding, if possible, a catheter tie-in technique as this promotes stasis The infusion should be continued until adequate blood pressure and tissue perfusion are maintained without therapy.

The medications used to manage hypotension are:

• Midodrine (PO): used to treat symptomatic orthostatic hypotension (OH) 2
• Norepinephrine (IV): used to restore and maintain adequate blood pressure in acute hypotensive states, including cardiac arrest 3 Key considerations when using these medications include:
• Monitoring blood pressure carefully, especially when used concomitantly with other agents that cause vasoconstriction
• Avoiding concomitant use of drugs that increase blood pressure
• Using caution in patients with renal or hepatic impairment, as well as those with a history of visual problems or diabetes 2

From the Research

Medications for Hypotension

The following medications are used to manage hypotension:

• Midodrine: a prodrug that increases standing systolic blood pressure and improves symptoms of orthostatic hypotension, such as dizziness and syncope 4, 5
• Fludrocortisone: a mineralocorticoid that increases blood volume and blood pressure, considered a first- or second-line pharmacological therapy for orthostatic hypotension 6
• Droxidopa: a medication that can help increase blood pressure and alleviate symptoms of orthostatic hypotension 7
• Pyridostigmine: a medication that can be used in patients who fail to respond to midodrine or droxidopa 7
• Atomoxetine: a medication with emerging evidence as a viable alternative treatment option, especially in patients with central autonomic failure 7
• Sympathomimetic agents: a class of medications that can be used to treat hypotension, although data surrounding their use is minimal 7
• Octreotide: a medication that can be used to treat hypotension, although data surrounding its use is minimal 7

Treatment Approach

Treatment of hypotension is best targeted at the underlying etiology, although this can be difficult to discern early in a patient's disease course 8. Nonpharmacological strategies, such as discontinuing offending medications, maintaining adequate hydration, and adding salt to the diet, are the primary treatment for primary orthostatic hypotension 7. If these fail, pharmacotherapy can help ameliorate symptoms. Medication management of primary orthostatic hypotension should be guided by patient-specific factors, such as tolerability, adverse effects, and drug-drug and drug-disease interactions 7.