What are the best initial steps to treat orthostatic hypotension?

From the Guidelines

The best initial steps to treat orthostatic hypotension include non-pharmacological measures, such as increasing fluid intake to 2-3 liters daily and salt consumption to 8-10 grams per day, unless contraindicated by heart or kidney conditions, as recommended by the most recent guidelines 1.

Non-Pharmacological Measures

These measures are crucial before considering medications. The following steps can be taken:

• Increase fluid intake to 2-3 liters daily and salt consumption to 8-10 grams per day, unless contraindicated by heart or kidney conditions.
• Avoid sudden position changes by rising slowly from lying or sitting positions.
• Consider elevating the head of the bed by 4-6 inches to reduce nocturnal diuresis.
• Use compression garments like waist-high stockings providing 30-40 mmHg pressure to help maintain venous return.
• Perform physical countermaneuvers such as crossing legs while standing, squatting, or tensing lower body muscles to temporarily increase blood pressure when symptoms occur.
• Avoid triggers like hot environments, large meals, alcohol, and prolonged standing.

Pharmacological Measures

If these measures are insufficient, medications like midodrine (2.5-10 mg three times daily) or fludrocortisone (0.1-0.3 mg daily) may be considered, as approved by the FDA for the treatment of orthostatic hypotension 1. These approaches work by increasing blood volume, preventing venous pooling, and enhancing vasoconstriction to maintain adequate cerebral perfusion when changing positions, thereby reducing symptoms like dizziness, lightheadedness, and risk of falls. It is essential to note that the therapeutic goal is to minimize postural symptoms rather than to restore normotension, and most individuals require both nonpharmacologic and pharmacologic measures 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 best initial steps to treat orthostatic hypotension include non-pharmacologic treatment, such as:

• Support stockings
• Fluid expansion
• Lifestyle alterations These measures should be tried first, as midodrine hydrochloride tablets should only be used in patients whose lives are considerably impaired despite standard clinical care 2.

From the Research

Initial Steps to Treat Orthostatic Hypotension

The initial steps to treat orthostatic hypotension involve a combination of non-pharmacological and pharmacological approaches.

• Reviewing and modifying medications that may aggravate or cause orthostatic hypotension is a crucial first step 3.
• Non-pharmacological measures such as optimizing blood volume, decreasing postural venous pooling, reducing heat and post-prandial induced vasodilation, emphasizing physical conditioning, and minimizing nocturnal diuresis can be effective in managing orthostatic hypotension 3, 4.
• Dietary modifications, compression garments, physical maneuvers, and avoiding environments that exacerbate symptoms are also recommended as initial treatment steps 5.

Non-Pharmacological Interventions

Non-pharmacological interventions can be used as the first line of treatment for orthostatic hypotension, especially in mild cases.

• Physical maneuvers such as leg crossing, leg muscle pumping/contractions, and bending forward can improve orthostatic hypotension 4.
• Abdominal compression and sleeping with head up can also be effective in managing orthostatic hypotension 4.
• Eating smaller, more frequent meals and drinking plenty of water can help increase blood pressure and reduce symptoms 4.

Pharmacological Interventions

Pharmacological interventions may be necessary for more severe cases of orthostatic hypotension.

• Midodrine is a commonly used medication for the treatment of orthostatic hypotension, which has been shown to be effective in increasing standing systolic blood pressure and improving clinical symptoms 6.
• Other medications such as fludrocortisone and droxidopa may also be used to treat orthostatic hypotension, although their use may be limited by potential side effects 5, 6.