From the Guidelines
Management of orthostatic hypotension involves both non-pharmacological and pharmacological approaches, with the most recent and highest quality study 1 suggesting that patients should focus on lifestyle modifications and medication management tailored to their individual needs.
Non-Pharmacological Approaches
- Adequate hydration (2-3 liters of fluid daily)
- Increased salt intake (10-20g daily unless contraindicated)
- Wearing compression stockings that extend to the waist
- Performing physical countermaneuvers like leg crossing and muscle tensing when standing
- Elevating the head of the bed by 4-6 inches to reduce nocturnal diuresis
- Avoiding triggers such as hot environments, large meals, alcohol, and rapid position changes
Pharmacological Approaches
- Fludrocortisone (starting at 0.1mg daily, maximum 0.3mg daily) to increase sodium retention and plasma volume
- Midodrine, an alpha-1 agonist, at 2.5-10mg three times daily (last dose before 6pm to avoid supine hypertension)
- Droxidopa (100-600mg three times daily) to increase norepinephrine levels, particularly useful in neurogenic orthostatic hypotension
- Pyridostigmine (30-60mg three times daily) may benefit patients with autonomic failure
- Other options include NSAIDs like indomethacin, erythropoietin for anemic patients, and octreotide for postprandial hypotension
Key Considerations
- Treatment should be individualized based on symptom severity, underlying cause, and comorbidities
- Careful monitoring for supine hypertension as a common side effect of these medications
- The most recent study 1 provides guidance on the management of orthostatic hypotension, emphasizing the importance of a comprehensive and multidisciplinary approach.
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 indication is based on midodrine's effect on increases in 1-minute standing systolic blood pressure, a surrogate marker considered likely to correspond to a clinical benefit. After initiation of treatment, midodrine hydrochloride tablets should be continued only for patients who report significant symptomatic improvement.
The management options for orthostatic hypotension include:
- Non-pharmacologic treatment: such as support stockings, fluid expansion, and lifestyle alterations
- Midodrine hydrochloride tablets: for patients whose lives are considerably impaired despite standard clinical care, with the goal of increasing 1-minute standing systolic blood pressure 2 It is essential to carefully evaluate the potential for supine and sitting hypertension at the beginning of midodrine therapy and to monitor blood pressure closely, especially when used concomitantly with other agents that cause vasoconstriction 2
From the Research
Management Options for Orthostatic Hypotension
The management of orthostatic hypotension involves a combination of non-pharmacological and pharmacological interventions.
- Non-pharmacological measures: Patient education is the cornerstone of management 3. Increasing fluid and sodium chloride intake, using compression stockings, tilt-table exercises, or abdominal binders, and avoiding large carbohydrate-rich meals are recommended 4.
- Pharmacological interventions: Several medications have been used to treat orthostatic hypotension, including:
- Fludrocortisone: a mineralocorticoid that increases blood volume and blood pressure 5
- Midodrine: a vasoactive drug that improves standing blood pressure 6
- Pyridostigmine: a cholinesterase inhibitor that improves standing blood pressure 6
- Droxidopa: a norepinephrine precursor that improves standing blood pressure 7
- Atomoxetine: a norepinephrine reuptake inhibitor that has been used off-label to treat orthostatic hypotension 4, 7
- Desmopressin: a synthetic hormone that increases blood volume and blood pressure 3, 7
Treatment Approaches
Treatment approaches may vary depending on the underlying cause of orthostatic hypotension and the severity of symptoms.
- Volume expansion: increasing fluid and sodium chloride intake to improve orthostatic tolerance 3
- Sympathomimetic agents: using medications that stimulate the sympathetic nervous system to improve standing blood pressure 3
- Supplementary agents: using medications such as desmopressin or erythropoietin to improve orthostatic tolerance in patients with refractory symptoms 3
Evidence-Based Recommendations
Evidence-based recommendations for the treatment of neurogenic orthostatic hypotension and related symptoms have been developed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system 7.