What are the treatment options for postural or neurogenic orthostatic hypotension?

Treatment Options for Postural or Neurogenic Orthostatic Hypotension

Treatment of orthostatic hypotension should begin with non-pharmacological measures, followed by pharmacological therapy with midodrine or fludrocortisone as first-line medications when symptoms persist despite conservative management. 1

Initial Assessment and Treatment Goals

• Treatment is required only when orthostatic hypotension is symptomatic
• The therapeutic goal is to minimize postural symptoms rather than to restore normotension
• Identify and address reversible causes (medication side effects, volume depletion)

Non-Pharmacological Interventions (First-Line)

Immediate Measures:

• Acute water ingestion: 480 mL of water for temporary relief (Class I recommendation) 1
• Physical counter-pressure maneuvers: Leg crossing, muscle tensing, squatting (Class IIa) 1
• Compression garments: Thigh-high or abdominal compression (Class IIa) 1

Lifestyle Modifications:

• Avoid medications that exacerbate orthostatic hypotension (psychotropic drugs, diuretics, α-adrenoreceptor antagonists) 1
• Gradual staged movements with postural change 1
• Head-up bed position during sleep (10-15 cm elevation) 2
• Increased fluid and salt intake if not contraindicated (Class IIb) 1
• Avoid large carbohydrate-rich meals 1
• Small, frequent meals rather than large meals 3

Pharmacological Interventions

First-Line Medications:

1. Midodrine (Class IIa recommendation) 1

   • Peripheral selective α1-adrenergic agonist
   • Dosing: Start with 2.5-5 mg three times daily, titrate up to 10 mg TID 2, 4
   • Maximum daily dose: 30-40 mg divided into 3-4 doses 2
   • First dose before arising, last dose 3-4 hours before bedtime 4
   • FDA-approved specifically for symptomatic orthostatic hypotension 1
   • Monitor for adverse effects: pilomotor reactions, pruritus, supine hypertension, bradycardia, GI symptoms, urinary retention 4

2. Fludrocortisone (Class IIa recommendation) 1

   • Acts through sodium retention and vessel wall effects
   • Initial dose: 0.05-0.1 mg daily, titrated to 0.1-0.3 mg daily 2
   • Monitor for adverse effects: supine hypertension, hypokalemia, edema, congestive heart failure 1

Second-Line Medications:

1. Droxidopa (Class IIa recommendation) 1

   • Effective for neurogenic OH due to Parkinson's disease, pure autonomic failure, and multiple system atrophy 1
   • May reduce falls according to small studies 1

2. Pyridostigmine (Class IIb recommendation) 1

   • May benefit patients refractory to other treatments 1
   • Can improve OH without worsening supine hypertension 5

3. Octreotide (Class IIb recommendation) 1

   • May benefit patients with refractory recurrent postprandial or neurogenic OH 1

4. Erythropoietin 1

   • Consider in patients with hemoglobin levels under 11 g/dL
   • Administered at 25-75 U/kg three times weekly

Special Considerations

Supine Hypertension Management

• Take last dose of midodrine at least 4 hours before bedtime 4
• Elevate head of bed by 10-15 cm during sleep 2
• Target systolic blood pressure <180 mmHg when supine 2

Combination Therapy

• If response to midodrine is inadequate, consider combination with fludrocortisone 2
• When using fludrocortisone with midodrine, monitor closely for worsening supine hypertension 4

Treatment Monitoring

• Continue medication only in patients who report significant symptomatic improvement 4
• Monitor renal function prior to and during midodrine therapy in patients with renal impairment 4
• Use caution with midodrine in patients with urinary retention problems 4

Treatment Algorithm

1. Start with non-pharmacological measures
2. If symptoms persist, add midodrine or fludrocortisone
3. If inadequate response, consider combination therapy or second-line agents
4. Monitor for supine hypertension and adjust dosing accordingly
5. Continue only if significant symptomatic improvement occurs