From the Guidelines
Medications commonly used to treat orthostatic hypotension include midodrine, droxidopa, fludrocortisone, and pyridostigmine, with midodrine being a preferred option due to its efficacy in reducing syncope recurrence, as shown in a meta-analysis of 5 RCTs 1.
Treatment Options
- Midodrine, a direct alpha-1 agonist, is usually dosed at 2.5-10 mg three times daily, with the last dose taken at least 4 hours before bedtime to avoid supine hypertension.
- Droxidopa is prescribed at 100-600 mg three times daily and works by converting to norepinephrine to increase blood pressure.
- Fludrocortisone is typically started at 0.1 mg daily and can be increased to 0.2 mg daily, working by increasing sodium retention and expanding blood volume.
- Pyridostigmine at 30-60 mg twice or three times daily may help patients with autonomic failure by enhancing sympathetic ganglionic transmission.
Non-Pharmacological Approaches
- Increased salt and fluid intake, compression stockings, and avoiding rapid position changes are recommended as initial treatments for orthostatic hypotension.
- Physical counter-pressure maneuvers, such as leg crossing and squatting, can also be beneficial in patients with neurogenic orthostatic hypotension.
Individualized Treatment
Treatment should be individualized based on symptom severity, underlying causes, and potential side effects, with the goal of reducing symptoms like dizziness and falls rather than normalizing blood pressure measurements, as supported by the 2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope 1.
Recent Guidelines
The 2021 standards of medical care in diabetes also recommend midodrine and droxidopa as approved treatments for orthostatic hypotension, highlighting the importance of individualized treatment plans 1.
From the FDA Drug Label
Midodrine hydrochloride tablets are indicated for the treatment of symptomatic orthostatic hypotension (OH) Midodrine forms an active metabolite, desglymidodrine, that is an alpha1-agonist, and exerts its actions via activation of the alpha-adrenergic receptors of the arteriolar and venous vasculature, producing an increase in vascular tone and elevation of blood pressure.
Medications for Orthostatic Hypotension:
- Midodrine (PO): is used to treat symptomatic orthostatic hypotension (OH) 2, 2, 2. It works by increasing vascular tone and elevating blood pressure through its active metabolite, desglymidodrine, which is an alpha1-agonist.
From the Research
Medications for Orthostatic Hypotension
Medications used to treat orthostatic hypotension include:
- Fludrocortisone, a mineralocorticoid that increases blood volume and blood pressure 3
- Midodrine, a peripheral alpha-adrenergic agonist that increases standing blood pressure and improves symptoms of orthostatism 4, 5
- Droxidopa, a pressor agent that can be used in combination with fludrocortisone and midodrine to improve standing blood pressure 6
Mechanism of Action
These medications work by:
- Increasing blood volume and blood pressure (fludrocortisone) 3
- Stimulating alpha-adrenergic receptors to increase vascular tone and blood pressure (midodrine) 4, 5
- Increasing norepinephrine levels to improve blood pressure regulation (droxidopa) 6
Efficacy and Safety
Studies have shown that:
- Fludrocortisone may be effective in improving orthostatic symptoms, but the evidence is very uncertain 3
- Midodrine is effective in increasing standing blood pressure and improving symptoms of orthostatic hypotension, with a favorable safety profile 4, 5
- The combination of fludrocortisone, midodrine, and droxidopa may be effective in improving standing blood pressure and reducing symptoms of orthostatic hypotension 6
Patient Management
Treatment of orthostatic hypotension should be individualized and may involve: