From the Guidelines
The most effective treatment for orthostatic hypotension involves a combination of non-pharmacological and pharmacological approaches, with the goal of reducing falls and improving quality of life, as recommended in the 2023 ACC expert consensus decision pathway 1. The treatment plan should start with lifestyle modifications, including rising slowly from sitting or lying positions, staying hydrated with 2-3 liters of fluid daily, and increasing salt intake (8-10g/day if not contraindicated) 1.
- Physical countermaneuvers like crossing legs when standing or tensing lower body muscles can help maintain blood pressure.
- Wearing compression stockings, and avoiding alcohol and large meals can also be beneficial. If these measures are insufficient, medications may be necessary, with first-line pharmacological options including:
- Fludrocortisone (starting at 0.1mg daily, maximum 0.3mg daily), which enhances sodium retention and increases blood volume 1.
- Midodrine (2.5-10mg three times daily), an alpha-1 agonist that increases vascular tone 1.
- Droxidopa (100-600mg three times daily) is another option that converts to norepinephrine 1. For neurogenic orthostatic hypotension, pyridostigmine (30-60mg three times daily) may be beneficial, as it can improve orthostatic tolerance through increases in peripheral vascular resistance and blood pressure 1. These medications should be taken early in the day to avoid nocturnal hypertension, and the last dose should be at least 4 hours before bedtime. Treatment effectiveness should be measured by symptom improvement rather than blood pressure readings alone, as the goal is to reduce falls and improve quality of life. It is essential to consider the potential side effects and interactions of these medications, particularly in patients with cardiac involvement or other comorbidities, and to consult with a geriatric specialist when treating older adults with orthostatic hypotension 1.
From the FDA Drug Label
Midodrine hydrochloride tablets are indicated for the treatment of symptomatic orthostatic hypotension (OH) The treatment for orthostatic hypotension is midodrine hydrochloride tablets.
- Key points:
- Midodrine should be used in patients whose lives are considerably impaired despite standard clinical care.
- The indication is based on midodrine's effect on increases in 1-minute standing systolic blood pressure.
- After initiation of treatment, midodrine hydrochloride tablets should be continued only for patients who report significant symptomatic improvement 2.
From the Research
Treatment for Orthostatic Hypotension
The treatment for orthostatic hypotension can be divided into non-pharmacologic and pharmacologic approaches.
- Non-pharmacologic strategies include:
- Avoiding large carbohydrate-rich meals
- Limiting alcohol consumption
- Maintaining adequate hydration
- Adding salt to foods
- Using compression stockings, tilt-table exercises, or abdominal binders 3
- Pharmacologic treatments include:
- Midodrine and fludrocortisone, which are considered first-line pharmacologic treatments for orthostatic hypotension (OH) 4
- Fludrocortisone is a mineralocorticoid that increases blood volume and blood pressure, and is considered the first- or second-line pharmacological therapy for orthostatic hypotension alongside mechanical and positional measures 5
- Atomoxetine, which has been shown to be effective and safe in improving symptoms and blood pressure control in elderly patients with primary orthostatic hypotension 3
- Pyridostigmine, droxidopa, pseudoephedrine, and ocetreotide, which are also used to treat orthostatic hypotension 3
Compression Therapy
Compression therapy can also be used to treat orthostatic hypotension, with full-length compression (lower limbs and abdomen) and compression of solely the abdomen being found to be superior to knee-length and thigh-length compression 6.
Efficacy of Midodrine
Midodrine has been shown to be efficacious and safe in the treatment of neurogenic orthostatic hypotension, with improvements in standing systolic blood pressure, symptoms of lightheadedness, and global symptom relief score 7.
Duration of Treatment
The duration of treatment for orthostatic hypotension can vary, with one study finding that the overall median persistence on fludrocortisone and midodrine was 254 and 259 days, respectively 4.