How is orthostatic hypertension managed?

From the Guidelines

Orthostatic hypertension is not directly addressed in the provided guidelines, which focus on orthostatic hypotension and the management of elevated blood pressure and hypertension. However, the management of orthostatic hypotension, as outlined in the 2024 ESC guidelines for the management of elevated blood pressure and hypertension 1, can provide some insight into how to approach orthostatic changes in blood pressure. The guidelines recommend testing for orthostatic hypotension before starting or intensifying BP-lowering medication, by having the patient sit or lie for 5 min and then measuring BP 1 and/or 3 min after standing 1. For patients with supine hypertension, it is recommended to pursue non-pharmacological approaches as the first-line treatment of orthostatic hypotension, and to switch BP-lowering medications that worsen orthostatic hypotension to an alternative BP-lowering therapy 1. Some key points to consider in managing orthostatic changes in blood pressure include:

• Maintaining BP-lowering drug treatment lifelong, even beyond the age of 85 years, if well tolerated 1
• Testing for orthostatic hypotension before starting or intensifying BP-lowering medication 1
• Pursuing non-pharmacological approaches as the first-line treatment of orthostatic hypotension among persons with supine hypertension 1
• Switching BP-lowering medications that worsen orthostatic hypotension to an alternative BP-lowering therapy 1 It is essential to note that the provided guidelines do not specifically address orthostatic hypertension, and therefore, the management approach may differ. In real-life clinical practice, it is crucial to prioritize the individual patient's needs, symptoms, and underlying conditions when managing orthostatic changes in blood pressure. The primary goal is to minimize morbidity, mortality, and improve quality of life, while also considering the potential risks and benefits of different treatment approaches. In the absence of specific guidelines for orthostatic hypertension, a cautious and individualized approach, taking into account the patient's overall health status and medical history, is recommended.

From the FDA Drug Label

Prazosin hydrochloride capsules are indicated for the treatment of hypertension, to lower blood pressure. The FDA drug label does not answer the question.

From the Research

Orthostatic Hypertension Management

• Orthostatic hypertension is a condition where blood pressure increases when standing up from a sitting or lying down position, which can be challenging to manage, especially in patients with hypertension 2.
• The management of orthostatic hypertension involves a combination of lifestyle modifications and pharmacological interventions.
• Lifestyle modifications include:
  • Maintaining a healthy body weight 3
  • Moderating alcohol consumption 3
  • Regular exercise 3
  • Reducing sodium intake 3
  • Stress management 3
• Pharmacological interventions for orthostatic hypertension are limited, but some studies suggest that:
  • Angiotensin receptor blockers and calcium channel blockers may be preferable antihypertensives for patients with orthostatic hypertension 2
  • Bedtime doses of short-acting antihypertensives may be effective for patients with isolated supine hypertension 2
  • Removing drugs that can worsen orthostatic hypertension, such as tamsulosin, tizanidine, sildenafil, trazodone, and carvedilol, is crucial 2
• Additional treatments for orthostatic hypertension include:
  • Abdominal binders to prevent orthostatic hypotension 2
  • Acarbose to prevent postprandial hypotension 2
  • Atomoxetine and pyridostigmine to improve upright blood pressure 2
  • Oral water bolus to acutely increase blood pressure in autonomic failure patients 2
  • Midodrine and droxidopa as traditional pressor agents, administered at the lowest dose and frequency that improves symptoms 2

Challenges in Managing Orthostatic Hypertension

• Managing orthostatic hypertension in patients with hypertension can be challenging due to the complexity of the condition and the need to balance the treatment of both conditions 2.
• Uncontrolled hypertension can worsen orthostatic hypertension, making it essential to manage both conditions simultaneously 2.
• The use of alpha 1-adrenoceptor antagonists, such as prazosin, can cause orthostatic hypotension, especially after the first dose, and requires careful monitoring 4, 5.