From the Guidelines
Postural hypotension can be effectively managed through a combination of lifestyle modifications and medications, with the primary goal of minimizing postural symptoms and improving quality of life. The most recent and highest quality study, published in 2024 1, recommends a multifaceted approach to managing postural hypotension.
Lifestyle Modifications
Key lifestyle modifications include:
- Rising slowly from sitting or lying positions to prevent sudden drops in blood pressure
- Staying well-hydrated by drinking 2-3 liters of water daily
- Increasing salt intake, unless contraindicated by other conditions, to help expand blood volume
- Avoiding alcohol and large meals, which can exacerbate hypotension
- Wearing compression stockings that extend to the waist to reduce venous pooling
Physical Countermeasures
Physical countermeasures such as:
- Crossing legs while standing
- Contracting arm muscles
- Squatting can help maintain blood pressure by increasing vascular tone and reducing blood pooling in the lower extremities.
Medication Options
For medication options, midodrine (ProAmatine) 2.5-10 mg three times daily and droxidopa (Northera) 100-600 mg three times daily are approved by the FDA for the treatment of orthostatic hypotension. These medications work by either expanding blood volume or increasing vascular tone to prevent blood pooling in the lower extremities when standing. Fludrocortisone (Florinef) 0.1-0.3 mg daily can also increase blood volume, but its use may be limited by supine hypertension.
Monitoring and Adjustment
Regular monitoring of blood pressure in both sitting and standing positions is essential to assess the effectiveness of these interventions. Additionally, discontinuing or modifying medications that may worsen hypotension, such as diuretics, certain antihypertensives, or antidepressants, after consulting with a healthcare provider, is crucial for optimal management.
Overall, managing postural hypotension requires a tailored approach that considers the individual's specific needs and health status, with the goal of improving symptoms, preventing complications, and enhancing 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 After initiation of treatment, midodrine hydrochloride tablets should be continued only for patients who report significant symptomatic improvement.
To manage postural hypotension, midodrine can be used as it is indicated for the treatment of symptomatic orthostatic hypotension. However, it should be used with caution and only in patients whose lives are considerably impaired despite standard clinical care, including:
- Non-pharmacologic treatment such as support stockings
- Fluid expansion
- Lifestyle alterations The treatment should be continued only for patients who report significant symptomatic improvement 2.
From the Research
Management of Postural Hypotension
To manage postural hypotension, several strategies can be employed, including:
- Non-pharmacological interventions, such as increasing fluid and salt intake, and venous compression methods 3
- Physical manoeuvres, like leg-crossing, bending forward, and placing a foot on a chair, which can help increase mean arterial pressure and reduce symptoms of orthostatic hypotension 4
- Pharmacological treatments, including:
- Fludrocortisone, a mineralocorticoid that increases blood volume and blood pressure, which has been shown to be effective in treating postural hypotension secondary to levodopa therapy 5 and is considered a first- or second-line treatment for orthostatic hypotension 6
- Midodrine, an α-1 adrenergic agonist that is a direct vasoconstrictor, which has been compared to fludrocortisone in terms of safety and efficacy 7
Pharmacological Treatment Options
When considering pharmacological treatment options, it is essential to weigh the benefits and risks of each medication. For example:
- Fludrocortisone has been associated with a higher risk of all-cause hospitalizations compared to midodrine in patients with orthostatic hypotension, particularly among those with a history of congestive heart failure 7
- The evidence for the effects of fludrocortisone on blood pressure, orthostatic symptoms, and adverse events in people with orthostatic hypotension is very uncertain, highlighting the need for further research 6
Importance of Individualized Treatment
Given the complexity of postural hypotension and the variability in patient responses to different treatments, it is crucial to develop an individualized treatment plan that takes into account the underlying cause of the condition, as well as the patient's medical history and current health status. This may involve a combination of non-pharmacological and pharmacological interventions, as well as regular monitoring and adjustments to the treatment plan as needed.