From the Guidelines
The management plan for a patient with orthostatic hypotension taking fludrocortisone and midodrine should prioritize optimizing medication regimens and implementing non-pharmacological strategies to minimize morbidity, mortality, and improve quality of life. According to the most recent and highest quality study 1, the management of orthostatic hypotension involves a multifaceted approach.
Medication Management
- Fludrocortisone typically starts at 0.1 mg daily and can be titrated up to 0.2-0.3 mg daily if needed, while midodrine usually begins at 2.5-5 mg three times daily (morning, midday, and late afternoon, but not after 6 PM to avoid supine hypertension) 1.
- Monitor blood pressure in both supine and standing positions to assess effectiveness.
Non-Pharmacological Strategies
- Patients should increase salt and fluid intake (aiming for 2-3 liters daily) to expand plasma volume and reduce symptoms of orthostatic hypotension 1.
- Wear compression stockings extending to at least the thigh to reduce venous pooling and improve orthostatic tolerance 1.
- Practice positional changes gradually (sitting before standing) to reduce the risk of orthostatic hypotension.
- Elevating the head of the bed by 4-6 inches can reduce nocturnal diuresis and improve orthostatic tolerance.
Monitoring and Adverse Effects
- Regular monitoring for adverse effects is essential: check for peripheral edema, supine hypertension, and electrolyte imbalances with fludrocortisone; and watch for piloerection, scalp tingling, urinary retention, and supine hypertension with midodrine 1.
- These medications work through complementary mechanisms - fludrocortisone expands plasma volume through sodium retention, while midodrine provides direct alpha-1 adrenergic vasoconstriction - making them effective when combined for patients with persistent symptoms.
Additional Considerations
- Other non-pharmacological strategies such as physical counter-pressure maneuvers (e.g., leg crossing, squatting) and encouraging increased salt and fluid intake may be beneficial in selected patients with neurogenic orthostatic hypotension 1.
- The use of other medications such as droxidopa, pyridostigmine, and octreotide may be considered in patients who are refractory to fludrocortisone and midodrine 1.
From the FDA Drug Label
Midodrine should be used with caution in orthostatic hypotensive patients who are also diabetic, as well as those with a history of visual problems who are also taking fludrocortisone acetate, which is known to cause an increase in intraocular pressure and glaucoma. Midodrine has been used in patients concomitantly treated with salt-retaining steroid therapy (i.e., fludrocortisone acetate), with or without salt supplementation. The potential for supine hypertension should be carefully monitored in these patients and may be minimized by either reducing the dose of fludrocortisone acetate or decreasing the salt intake prior to initiation of treatment with midodrine
The management plan for a patient with orthostatic hypotension taking fludrocortisone and midodrine should include:
- Close monitoring of blood pressure to minimize the risk of supine hypertension
- Caution when using midodrine in patients with a history of visual problems due to the potential increase in intraocular pressure and glaucoma caused by fludrocortisone acetate
- Assessment of renal and hepatic function prior to initiating therapy and subsequently, as appropriate
- Adjustment of the dose of fludrocortisone acetate or salt intake to minimize the potential for supine hypertension 2 2
From the Research
Management Plan for Orthostatic Hypotension
The patient is experiencing orthostatic hypotension and is currently taking fludrocortisone and midodrine. The management plan for this patient should focus on improving symptoms and reducing the risk of complications.
Medication Management
- Fludrocortisone is a mineralocorticoid that increases blood volume and blood pressure, and is considered a first- or second-line pharmacological therapy for orthostatic hypotension 3.
- Midodrine is a prodrug that undergoes enzymatic hydrolysis to form its pharmacologically active metabolite, desglymidodrine, which is a selective alpha 1-adrenoceptor agonist that increases standing systolic blood pressure and improves symptoms of orthostatic hypotension 4, 5.
- The combination of fludrocortisone and midodrine may be effective in increasing 24-h systolic blood pressure and reducing systolic blood pressure drops 6.
Monitoring and Adjustments
- Regular monitoring of blood pressure and heart rate is essential to assess the effectiveness of the treatment plan and make adjustments as needed.
- The patient should be educated on how to monitor their blood pressure and report any changes or concerns to their healthcare provider.
- The dosage of fludrocortisone and midodrine may need to be adjusted based on the patient's response to treatment and the presence of any adverse effects.
Non-Pharmacological Measures
- Non-pharmacological measures such as increasing fluid and salt intake, venous compression methods, and avoiding the supine position can also be effective in managing orthostatic hypotension 3, 7.
- The patient should be encouraged to make lifestyle changes to help manage their condition, such as increasing their fluid and salt intake, avoiding strenuous activities, and taking regular breaks to rest.