Is it safe to discharge a patient with symptomatic orthostatic hypotension from the hospital and how can the risks be mitigated?

From the Guidelines

Discharging a patient with symptomatic orthostatic hypotension from the hospital can be safe with appropriate risk mitigation strategies in place, as long as the patient is hemodynamically stable and able to manage their condition at home. The decision to discharge should be based on the severity of symptoms, underlying cause, and the patient's ability to manage at home. Before discharge, ensure the patient is hemodynamically stable with minimal symptoms when upright.

Key Considerations

• Implement a stepwise approach including non-pharmacological measures such as:
  • Gradual position changes
  • Compression stockings (30-40 mmHg)
  • Adequate hydration (2-3 liters daily)
  • Increased salt intake (8-10g daily if no contraindications)
  • Elevation of the head of the bed by 4-6 inches
• Pharmacological options include:
  • Fludrocortisone (starting at 0.1mg daily, maximum 0.3mg daily) to enhance sodium retention
  • Midodrine (2.5-10mg three times daily, last dose before 6pm) for vasoconstriction
  • Droxidopa (100-600mg three times daily) for neurogenic orthostatic hypotension, as supported by 1

Patient Education and Follow-up

• Patient education is crucial - teach them to recognize symptoms, avoid triggers like hot environments and large meals, and rise slowly from lying or sitting positions
• Arrange close follow-up within 1-2 weeks and ensure a clear plan for medication adjustment
• Home blood pressure monitoring in both sitting and standing positions helps track progress, as noted in 1 and 1 These measures work by improving venous return, increasing blood volume, and enhancing vascular tone, thereby maintaining cerebral perfusion during position changes and reducing the risk of falls or syncope after discharge. According to 1, intensive diabetes therapy and lifestyle intervention may also improve outcomes in patients with symptomatic orthostatic hypotension. However, the most recent and highest quality study 1 supports the use of midodrine and droxidopa as effective treatments for orthostatic hypotension.

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 FDA drug label does not answer the question.

From the Research

Discharge Considerations for Patients with Symptomatic Orthostatic Hypotension

• Discharging a patient with symptomatic orthostatic hypotension from the hospital requires careful consideration of the risks involved, as orthostatic hypotension can lead to falls, injuries, and other complications 2.
• Before discharge, it is essential to ensure that the patient's condition is stable and that they are able to manage their symptoms effectively.

Mitigating Risks

• Non-pharmacologic strategies can be used to mitigate the risks associated with orthostatic hypotension, including:
  • Avoiding large carbohydrate-rich meals
  • Limiting alcohol consumption
  • Maintaining adequate hydration
  • Adding salt to foods
  • Using compression stockings, tilt-table exercises, or abdominal binders 3, 4, 5
• Pharmacologic treatment options, such as fludrocortisone, midodrine, pyridostigmine, and droxidopa, may also be considered, but their use should be carefully evaluated and monitored 3, 4, 2, 5.

Specific Considerations

• Patients with a history of congestive heart failure may require closer monitoring and more aggressive management of their orthostatic hypotension, as they are at higher risk of hospitalization and other complications 2.
• The use of abdominal binders and compression stockings may be effective in improving mobility and reducing symptoms in patients with orthostatic hypotension, particularly those with Parkinson's disease 6.