From the Guidelines
Medications for orthostatic hypotension include midodrine (2.5-10 mg three times daily, last dose before 6 PM) and droxidopa (100-600 mg three times daily), which are approved by the FDA for the treatment of orthostatic hypotension. These medications work by increasing blood pressure, with midodrine being a vasoconstrictor and droxidopa acting to raise blood pressure. Before starting medications, non-pharmacological approaches should be tried, including:
- Increased fluid intake (2-3 liters daily)
- Salt supplementation (6-10 g daily)
- Compression stockings
- Avoiding rapid position changes Treatment should begin with the lowest effective dose to minimize side effects. Blood pressure monitoring is essential during treatment, as these medications can cause supine hypertension, especially at night. Patients should elevate the head of their bed by 4-6 inches when sleeping. Other medications that may help include NSAIDs like indomethacin (25-50 mg three times daily), desmopressin (0.1-0.4 mg at bedtime), and caffeine, though these are typically second-line options due to side effect profiles 1.
The goal of treatment is to minimize postural symptoms rather than to restore normotension, and physical activity and exercise should be encouraged to avoid deconditioning, which is known to exacerbate orthostatic intolerance, and volume repletion with fluids and salt is critical 1. Supine blood pressure tends to be much higher in these patients, often requiring treatment of blood pressure at bedtime with shorter-acting drugs that also affect baroreceptor activity 1.
It's worth noting that the most recent and highest quality studies support the use of midodrine and droxidopa as first-line treatments for orthostatic hypotension 1. Other medications, such as fludrocortisone and pyridostigmine, may also be beneficial, but the evidence is less strong or more equivocal 1.
From the FDA Drug Label
Midodrine hydrochloride tablets are indicated for the treatment of symptomatic orthostatic hypotension (OH) Midodrine has been studied in 3 principal controlled trials, one of 3-weeks duration and 2 of 1 to 2 days duration. The midodrine-treated patients (10 mg t.i.d., with the last dose not later than 6 P.M.) had significantly higher (by about 20 mmHg) 1-minute standing systolic pressure 1 hour after dosing A 1-day, dose-response trial, single doses of 0,2.5,10 and 20 mg of midodrine were given to 25 patients. The 10 and 20 mg doses produced increases in standing 1-minute systolic pressure of about 30 mmHg at 1 hour;
The medication for orthostatic hypotension is midodrine. The dose is 10 mg t.i.d. (three times a day), with the last dose not later than 6 P.M. 2 2
From the Research
Medications for Orthostatic Hypotension
The following medications are used to treat orthostatic hypotension:
- Fludrocortisone: a mineralocorticoid that increases blood volume and blood pressure 3
- Midodrine: an alpha-agonist that improves orthostatic blood pressure by increasing vasomotor and venomotor tone 4
- Pyridostigmine: an acetylcholinesterase inhibitor that can be used to treat orthostatic hypotension 5, 3
- Droxidopa: a synthetic precursor of norepinephrine that can be used to treat neurogenic orthostatic hypotension 6
- Atomoxetine: a norepinephrine reuptake inhibitor that can be used to treat orthostatic hypotension, particularly in elderly patients 5
- Pseudoephedrine: a sympathomimetic amine that can be used to treat orthostatic hypotension 5
- Octreotide: a somatostatin analogue that can be used to treat severe postprandial hypotension 6
Doses of Medications
The doses of these medications vary:
- Midodrine: 10 mg three times a day 4
- Fludrocortisone: the dose is not specified in the available evidence, but it is considered a first- or second-line pharmacological therapy for orthostatic hypotension 3, 7
- Atomoxetine: low-dose atomoxetine is effective and safe for symptom improvement and blood pressure control in elderly patients with primary orthostatic hypotension, but the exact dose is not specified 5
- Droxidopa: the dose is not specified in the available evidence, but it is recommended for pharmacological treatment of neurogenic orthostatic hypotension 6
Non-Pharmacological Strategies
Non-pharmacological strategies are also important in the treatment of orthostatic hypotension, including: