From the Guidelines
Patients with orthostatic hypotension should be managed with both non-pharmacological and pharmacological interventions before discharge, prioritizing the most recent and highest quality evidence available, such as the 2024 ESC guidelines for the management of elevated blood pressure and hypertension 1.
Non-Pharmacological Interventions
Non-pharmacological measures are crucial in managing orthostatic hypotension and include:
- Gradual position changes (sitting before standing)
- Compression stockings to improve venous return
- Increased fluid intake (2-3 liters daily)
- Increased salt consumption (8-10g daily unless contraindicated)
- Elevating the head of the bed by 10-20 degrees to reduce nocturnal diuresis
- Avoiding triggers like hot environments, large meals, and alcohol
Pharmacological Interventions
Pharmacological options, as recommended by recent guidelines such as the 2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope 1, include:
- Fludrocortisone (starting at 0.1mg daily, maximum 0.3mg daily) which enhances sodium retention
- Midodrine (2.5-10mg three times daily, last dose before 6pm) which increases peripheral vascular resistance
- Droxidopa (100-600mg three times daily) for neurogenic orthostatic hypotension
Patient Education and Medication Review
Patient education is crucial, teaching them to recognize symptoms like dizziness, lightheadedness, and blurred vision, and to employ countermeasures such as crossing legs, squatting, or tensing muscles when symptoms occur. Any medications potentially causing or worsening hypotension should be reviewed and adjusted if possible, as suggested by the 2021 standards of medical care in diabetes 1 and other guidelines. These interventions work by improving venous return, increasing blood volume, enhancing vasoconstriction, or reducing vasodilation, all of which help maintain blood pressure when changing positions and reduce the risk of falls and associated complications.
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 help that can be provided to a patient with orthostatic hypotension in the ward before discharge includes:
- Non-pharmacologic treatment: such as support stockings
- Fluid expansion: to help increase blood volume
- Lifestyle alterations: to help manage symptoms of orthostatic hypotension Midodrine hydrochloride tablets can be used to treat symptomatic orthostatic hypotension, but should be used with caution and only in patients who report significant symptomatic improvement 2.
From the Research
Non-Pharmacological Interventions
- Avoiding large carbohydrate-rich meals 3
- Limiting alcohol consumption 3
- Maintaining adequate hydration 3
- Adding salt to foods 3
- Using compression stockings, tilt-table exercises, or abdominal binders 3, 4
- Patient education 4
Pharmacological Interventions
- Fludrocortisone 3, 5, 6, 7
- Midodrine 3, 5, 4, 6, 7
- Pyridostigmine 3, 4
- Droxidopa 3, 4
- Atomoxetine 3, 4
- Pseudoephedrine 3
- Octreotide 3, 4
- Acarbose (for severe postprandial hypotension) 4
- Voglibose or caffeine (for severe postprandial hypotension) 4