From the Guidelines
Treatment of postural hypotension should prioritize non-pharmacological measures, including gradual position changes, increasing fluid and salt intake, wearing compression stockings, and physical countermaneuvers, with medications such as midodrine, droxidopa, and fludrocortisone considered if these measures are insufficient. The goal of treatment is to minimize postural symptoms rather than to restore normotension, and patients should be encouraged to maintain adequate hydration and salt intake, avoid medications that aggravate hypotension, and use compressive garments over the legs and abdomen if necessary 1. Physical activity and exercise should be encouraged to avoid deconditioning, which can exacerbate orthostatic intolerance, and volume repletion with fluids and salt is critical 1. Medications such as midodrine and droxidopa are approved by the FDA for the treatment of orthostatic hypotension, and fludrocortisone may be beneficial in patients with neurogenic orthostatic hypotension 1. Some key non-pharmacological measures include:
- Gradual position changes, such as sitting before standing
- Increasing fluid intake to 2-3 liters daily
- Increasing salt consumption to 8-10g daily
- Wearing compression stockings
- Elevating the head of the bed by 4-6 inches
- Avoiding alcohol, large meals, and hot environments
- Physical countermaneuvers like crossing legs while standing, tensing lower body muscles, and squatting If these measures are insufficient, medications may be necessary, and patients should monitor their blood pressure in different positions to assess treatment effectiveness and report any supine hypertension, which is a common side effect of these medications 1.
From the FDA Drug Label
Midodrine hydrochloride is indicated for the treatment of symptomatic orthostatic hypotension (OH) Because midodrine hydrochloride 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 hydrochloride's effect on increases in 1-minute standing systolic blood pressure, a surrogate marker considered likely to correspond to a clinical benefit.
The treatment options for postural hypotension include midodrine hydrochloride, which 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:
From the Research
Treatment Options for Postural Hypotension
The treatment of postural hypotension involves a combination of non-pharmacologic and pharmacologic measures. The primary goal of treatment is to decrease symptoms, increase standing time, and improve activities of daily life 3.
- Non-pharmacologic measures include:
- Optimizing blood volume
- Decreasing postural venous pooling
- Reducing heat and post-prandial induced vasodilation
- Emphasizing physical conditioning
- Minimizing nocturnal diuresis 3
- Sleeping with the head of the bed elevated 4
- Using compression stockings, tilt-table exercises, or abdominal binders 5
- Avoiding large carbohydrate-rich meals, limiting alcohol consumption, maintaining adequate hydration, and adding salt to foods 5
Pharmacologic Measures
Pharmacologic measures may be employed in conjunction with non-pharmacologic approaches, especially in cases with severe symptoms such as falls, syncope, or near-syncope 3.
- Pharmacologic options include:
Considerations for Treatment
It is essential to note that many patients can be treated adequately with non-pharmacologic measures and fludrocortisone 4. However, for patients who respond poorly to these measures, hospital admission and treatment with desmopressin may be necessary 4. Additionally, symptomatic postprandial hypotension should be identified early, and caffeine administered before eating may be helpful 4. The choice of treatment should be based on the individual patient's needs and response to therapy.