What is the first line of management for a patient with orthostatic hypotension?

First-Line Management of Orthostatic Hypotension

The first-line management for orthostatic hypotension should focus on non-pharmacological measures including adequate hydration with 2-3 liters of fluid daily, increased salt intake (10g NaCl/day), and physical counterpressure maneuvers. 1

Understanding Orthostatic Hypotension

Orthostatic hypotension (OH) is defined as a decrease in systolic blood pressure of ≥20 mmHg or a decrease in diastolic blood pressure of ≥10 mmHg within 3 minutes of standing compared to the sitting or supine position. The goal of treatment is to improve symptoms and functional capacity rather than achieving a specific blood pressure target.

Step-by-Step Management Approach

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

• Hydration and salt intake:

  • Maintain fluid intake of 2-3 liters per day
  • Increase salt intake to approximately 10g of NaCl daily (if not contraindicated) 1
  • Rapid cool water ingestion can be effective for immediate symptom relief 1

• Physical counterpressure maneuvers:

  • Leg crossing, squatting, and muscle tensing 1
  • These increase cardiac output and peripheral vascular resistance

• Positional adjustments:

  • Sleep with head of bed elevated (10°) to prevent nocturnal polyuria and maintain better fluid distribution 1
  • Avoid rapid position changes

• Compression garments:

  • Use abdominal binders or compression stockings to reduce venous pooling 1
  • Garments should be at least thigh-high and preferably include the abdomen

• Avoid triggering factors:

  • Large carbohydrate-rich meals
  • Prolonged standing
  • Hot environments
  • Alcohol consumption

Step 2: Medication Review and Adjustment

• Identify and discontinue medications that may cause or worsen OH:
  • Diuretics
  • Vasodilators
  • Alpha-blockers
  • Certain psychotropic drugs

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

1. First-line pharmacological options:

   • Midodrine (5-20 mg three times daily): An α-agonist that increases peripheral vascular resistance 1
   • Fludrocortisone (0.1-0.3 mg once daily): A mineralocorticoid that increases sodium retention and expands fluid volume 1

2. Second-line pharmacological options:

   • Droxidopa: Improves symptoms of neurogenic OH 1
   • Pyridostigmine: Beneficial in patients refractory to other treatments 1

Special Considerations

Neurogenic vs. Non-Neurogenic OH

• Neurogenic OH: Results from autonomic nervous system dysfunction

  • More likely to benefit from midodrine and droxidopa 1
  • Often associated with supine hypertension

• Non-Neurogenic OH: Results from volume depletion, medications, or other medical conditions

  • Focus on treating underlying cause
  • Volume expansion strategies are particularly important

Supine Hypertension

• Common complication in patients with neurogenic OH
• Manage by:
  • Avoiding supine position during the day
  • Elevating head of bed at night
  • Timing medications to avoid peak effect during sleep

Monitoring Response

• Assess symptom improvement rather than targeting specific blood pressure values
• Monitor for supine hypertension, especially with fludrocortisone and midodrine

Common Pitfalls to Avoid

1. Focusing solely on blood pressure numbers rather than symptom improvement and functional capacity

2. Aggressive pharmacological treatment without adequate trial of non-pharmacological measures

3. Failure to recognize and manage supine hypertension when treating OH

4. Overlooking medication-induced OH as a potentially reversible cause

5. Using beta-blockers which are not indicated for OH and may worsen symptoms 1

By following this algorithmic approach, most patients with orthostatic hypotension can achieve significant symptom improvement and better quality of life.