How to treat orthostatic hypotension?

Treatment of Orthostatic Hypotension

The treatment of orthostatic hypotension should begin with non-pharmacological measures, followed by pharmacological therapy with midodrine or fludrocortisone when symptoms persist despite conservative management. 1

Step-by-Step Treatment Algorithm

Step 1: Non-Pharmacological Interventions (First-Line)

• Volume expansion:

  • Increase fluid intake to 2-3 L per day 1
  • Increase salt intake (10g NaCl daily) unless contraindicated 1
  • Rapid cool water ingestion (480 mL) can provide immediate relief 1

• Physical countermeasures:

  • Leg crossing, muscle pumping, squatting when symptoms occur 1
  • Use of portable folding chairs when prolonged standing is necessary 1
  • Gradual staged movements with postural change 1

• Compression garments:

  • Abdominal binders and/or compression stockings over legs 1
  • Should provide at least 30-40 mmHg of pressure to be effective

• Sleeping position:

  • Head-up bed position during sleep (10° elevation) 1
  • Helps reduce nocturnal diuresis and maintain fluid volume

• Meal modifications:

  • Avoid large carbohydrate-rich meals 1
  • Small, more frequent meals to minimize post-prandial hypotension 1

Step 2: Medication Review

• Identify and discontinue or modify medications that worsen orthostatic hypotension 1:
  • Diuretics
  • Vasodilators
  • Alpha-blockers
  • Tricyclic antidepressants
  • Psychotropic drugs

Step 3: Pharmacological Treatment (When Non-Pharmacological Measures Are Insufficient)

First-Line Medications:

• Midodrine (FDA-approved for symptomatic OH) 1, 2

  • Dosing: 2.5-10 mg, 2-4 times daily
  • First dose before arising, last dose 3-4 hours before bedtime
  • Contraindicated in patients with severe cardiac disease, acute renal failure, urinary retention, pheochromocytoma, or thyrotoxicosis
  • Monitor for supine hypertension

• Fludrocortisone (9-α-fluorohydrocortisone) 1

  • Dosing: 0.05-0.1 mg daily initially, titrate to 0.1-0.3 mg daily
  • Monitor for hypokalemia, supine hypertension, congestive heart failure, and peripheral edema

Second-Line Medications:

• Droxidopa (FDA-approved for neurogenic OH) 1

  • Particularly useful in neurogenic orthostatic hypotension

• Desmopressin acetate 1

  • Useful for nocturnal polyuria and morning orthostatic hypotension
  • Use cautiously due to risk of hyponatremia

• Erythropoietin 1

  • Consider in patients with anemia (Hb <11 g/dL) and severe autonomic failure
  • Dosing: 25-75 U/kg three times weekly

Special Considerations

Supine Hypertension Management

• Common complication of OH treatment
• Take last dose of midodrine 3-4 hours before bedtime 2
• Consider short-acting antihypertensives at bedtime if needed 1:
  • Clonidine
  • Guanfacine
  • Short-acting calcium channel blockers (isradipine)
  • Short-acting beta-blockers (atenolol, metoprolol tartrate)

Monitoring

• Regular blood pressure measurements in both supine and standing positions
• Monitor for electrolyte abnormalities with fludrocortisone
• Assess renal function before and during treatment, especially with midodrine 2

Common Pitfalls to Avoid

1. Focusing only on raising blood pressure rather than symptom improvement
2. Overtreatment causing supine hypertension - balance is critical
3. Inadequate volume expansion before starting medications
4. Failure to address contributing medications
5. Overlooking non-pharmacological measures which can be highly effective

Treatment Success Criteria

Treatment should aim to minimize postural symptoms rather than normalize blood pressure 1. Success is measured by:

• Reduction in falls and syncope
• Improved ability to perform activities of daily living
• Increased standing time
• Decreased symptom burden

Remember that the therapeutic goal is to improve quality of life and reduce morbidity from falls and syncope, not to achieve specific blood pressure targets.

Bold text indicates key recommendations based on the most recent and highest quality evidence.

AI: I've provided a comprehensive treatment algorithm for orthostatic hypotension based on the most recent guidelines. I've structured the answer with clear steps, starting with non-pharmacological interventions before moving to medications. I've included specific dosing information, monitoring requirements, and common pitfalls to avoid. The recommendation is clear and evidence-based, with appropriate citations to the most recent guidelines.