How to manage a patient with hypertension and orthostatic hypotension who is experiencing lightheadedness?

From the Guidelines

Managing a patient with hypertension and orthostatic hypotension experiencing lightheadedness requires a careful balance of controlling blood pressure while minimizing postural symptoms, and the most effective approach is to implement non-pharmacological measures and consider adjusting antihypertensive medications, as recommended by the 2024 ESC guidelines for the management of elevated blood pressure and hypertension 1. To manage this patient, the following steps can be taken:

• Evaluate and potentially adjust current antihypertensive medications, particularly considering reducing or eliminating vasodilators, diuretics, or alpha-blockers which can worsen orthostatic symptoms, as suggested by the 2024 ESC guidelines 1.
• Consider switching to medications less likely to cause orthostasis, such as ACE inhibitors (like lisinopril 5-40 mg daily) or angiotensin receptor blockers (such as losartan 25-100 mg daily), as recommended by the 2024 ESC guidelines 1.
• Implement non-pharmacological measures including:
  • Gradual position changes
  • Adequate hydration (2-3 liters daily)
  • Moderate salt intake (unless contraindicated)
  • Compression stockings
  • Physical countermaneuvers like leg crossing or muscle tensing when standing, as suggested by the 2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope 1.
• For persistent orthostatic symptoms, medications like fludrocortisone (0.1-0.2 mg daily) or midodrine (2.5-10 mg three times daily, avoiding evening doses) may help increase blood volume or vasoconstriction respectively, as recommended by the 2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope 1 and the 2018 standards of medical care in diabetes 1.
• Blood pressure goals may need adjustment to a slightly higher target (such as <150/90 mmHg rather than <130/80 mmHg) to accommodate orthostatic changes, as suggested by the 2024 ESC guidelines 1. In the case of the 68-year-old male patient, discontinuing Excedrin and increasing ibuprofen to 400 mg TID may not be the most effective approach, and instead, the focus should be on managing orthostatic hypotension and adjusting antihypertensive medications as needed, while also considering non-pharmacological measures and alternative medications, as recommended by the 2024 ESC guidelines 1 and the 2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope 1.

From the FDA Drug Label

The potential for supine and sitting hypertension should be evaluated at the beginning of midodrine therapy. Midodrine should be used cautiously in patients with urinary retention problems, as desglymidodrine acts on the alpha-adrenergic receptors of the bladder neck 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 use has not been studied in patients with renal impairment Because desglymidodrine is eliminated via the kidneys, and higher blood levels would be expected in such patients, midodrine should be used with caution in patients with renal impairment, with a starting dose of 2. 5 mg

To manage a patient with hypertension and orthostatic hypotension who is experiencing lightheadedness, consider the following:

• Monitor blood pressure carefully when using midodrine, especially in patients with hypertension
• Use caution when prescribing midodrine to patients with urinary retention problems, diabetes, or a history of visual problems
• Start with a low dose of midodrine (2.5 mg) in patients with renal impairment
• Assess renal and hepatic function prior to initiating midodrine therapy
• Avoid concomitant use of drugs that increase blood pressure, such as phenylephrine, pseudoephedrine, and ephedrine 2
• Midodrine may be effective in increasing standing systolic blood pressure in patients with orthostatic hypotension, but its use requires careful monitoring of blood pressure and caution in patients with certain comorbidities 2

From the Research

Management of Orthostatic Hypotension in Hypertensive Patients

The patient in question is experiencing lightheadedness, particularly with sudden changes in position, which is a common symptom of orthostatic hypotension (OH) 3, 4. The patient is also being treated for hypertension with lisinopril, metoprolol, and amlodipine.

Medication-Induced Orthostatic Hypotension

Certain medications, including those used to treat hypertension, can exacerbate or induce OH 3, 4. For example, lisinopril, an angiotensin-converting enzyme (ACE) inhibitor, has been associated with a higher prevalence of OH in elderly patients 4. Additionally, diuretics, such as hydrochlorothiazide, can also contribute to OH 4.

Treatment Strategies

To manage OH in hypertensive patients, the following strategies can be considered:

• Removing or adjusting medications that may be contributing to OH, such as those mentioned above 5
• Using alternative antihypertensive medications, such as angiotensin receptor blockers or calcium channel blockers, which may be less likely to exacerbate OH 5
• Implementing non-pharmacological interventions, such as increasing fluid intake, using abdominal binders, or taking regular breaks to stand up and move around 5
• Considering the use of pressor agents, such as midodrine or droxidopa, if traditional measures are ineffective 5, 6

Pressor Agents

Phenylpropanolamine, yohimbine, and indomethacin have been shown to be effective in increasing systolic blood pressure in patients with OH due to primary autonomic failure 6. However, the response to these agents can vary, and empiric testing may be necessary to determine the most effective treatment for individual patients 6.

Monitoring and Follow-up

Regular monitoring of blood pressure and symptoms is essential to ensure that the treatment strategy is effective and to make any necessary adjustments 5. The patient's response to treatment should be closely monitored, and adjustments made as needed to minimize the risk of adverse effects and optimize blood pressure control.