From the Guidelines
Orthostatic hypotension is best managed through a combination of lifestyle modifications and medications, with the most recent and highest quality evidence recommending non-pharmacological approaches as the initial management strategy. The management of orthostatic hypotension should prioritize non-pharmacological approaches, including:
- Gradual position changes
- Increased fluid intake (2-3 liters daily)
- Increased salt consumption (8-10g daily)
- Wearing compression stockings that extend to the waist
- Elevating the head of the bed by 4-6 inches
- Avoiding triggers like hot environments, large meals, and alcohol These measures can help improve orthostatic symptoms and reduce the risk of falls and other complications, as supported by the 2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope 1.
If these measures are insufficient, pharmacological treatment can be initiated with medications such as:
- Fludrocortisone (starting at 0.1mg daily, maximum 0.3mg daily)
- Midodrine (2.5-10mg three times daily, with the last dose at least 4 hours before bedtime)
- Droxidopa (100-600mg three times daily)
- Pyridostigmine (30-60mg three times daily) These medications work by either increasing blood volume or causing peripheral vasoconstriction to maintain blood pressure upon standing, addressing the pathophysiological mechanism of inadequate compensatory vasoconstriction during positional changes, as discussed in the 2011 review on cardiovascular autonomic neuropathy in diabetes 1.
It is essential to note that the management of orthostatic hypotension should be individualized, taking into account the patient's underlying medical conditions, medications, and lifestyle. The 2009 European Heart Journal guidelines for the diagnosis and management of syncope also emphasize the importance of education and lifestyle modifications in managing orthostatic hypotension 1.
In terms of specific medications, midodrine is a first-line drug that exerts a pressor effect through both arteriolar constriction and venoconstriction of the capacitance vessels, as supported by the 2011 review on cardiovascular autonomic neuropathy in diabetes 1. The dosing of midodrine should be individually tailored, with the first dose taken before arising and use avoided several hours before planned recumbency, particularly in patients with documented supine hypertension.
Overall, the management of orthostatic hypotension requires a comprehensive approach that incorporates lifestyle modifications, medications, and individualized care to improve symptoms, reduce the risk of complications, and enhance quality of life.
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 patient should be cautioned to report symptoms of supine hypertension immediately. Symptoms may include cardiac awareness, pounding in the ears, headache, blurred vision, etc. Patients should be told that certain agents in over-the-counter products, such as cold remedies and diet aids, can elevate blood pressure, and therefore, should be used cautiously with midodrine, as they may enhance or potentiate the pressor effects of midodrine
Management of Orthostatic Hypotension
- Midodrine hydrochloride tablets are used to treat symptomatic orthostatic hypotension.
- Standard clinical care includes non-pharmacologic treatment, such as support stockings, fluid expansion, and lifestyle alterations.
- Patients should be cautioned to report symptoms of supine hypertension immediately.
- Certain agents in over-the-counter products, such as cold remedies and diet aids, can elevate blood pressure and should be used cautiously with midodrine 2 2.
From the Research
Management of Orthostatic Hypotension
Orthostatic hypotension can be managed through various nonpharmacologic and pharmacologic strategies.
- Nonpharmacologic strategies include:
- 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
- Pharmacologic treatment options are available if nonpharmacologic strategies fail, including:
Pharmacologic Treatment
Several studies have investigated the efficacy of different pharmacologic agents in managing orthostatic hypotension.
- Midodrine has been shown to be efficacious and safe in the treatment of neurogenic orthostatic hypotension 6
- Pyridostigmine may be as useful as fludrocortisone in the treatment of primary orthostatic hypotension, with fewer side effects 4
- Fludrocortisone is considered a first- or second-line pharmacological therapy for orthostatic hypotension, although the evidence for its effectiveness is very uncertain 5
- Atomoxetine has been reported to be an effective and safe agent for symptom improvement and blood pressure control in elderly patients with primary orthostatic hypotension 3
- Droxidopa reaches a strong recommendation level for pharmacological treatment of neurogenic orthostatic hypotension, along with midodrine 7