What are the management options for orthostatic hypotension?

Management of Orthostatic Hypotension

Non-pharmacological approaches should be the first-line treatment for orthostatic hypotension, followed by pharmacological therapy with midodrine or fludrocortisone when symptoms persist despite conservative measures. 1, 2

Definition and Diagnosis

Orthostatic hypotension 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 sitting or supine position.

• Before starting any treatment, test for orthostatic hypotension by having the patient sit or lie for 5 minutes, then measure BP at 1 and/or 3 minutes after standing 2
• Treatment is only necessary when orthostatic hypotension is symptomatic 1

Non-Pharmacological Management

First-Line Approaches:

• Acute water ingestion: 480 mL can provide temporary relief 1
• Physical counter-pressure maneuvers: leg crossing, muscle tensing, and squatting 1
• Compression garments: thigh-high or abdominal compression 1
• Increased fluid and salt intake: if not contraindicated by other conditions 1
• Dietary modifications:
  • Avoid large carbohydrate-rich meals
  • Consume small, frequent meals 1
• Positional changes:
  • Gradual staged movements when changing posture
  • Elevate head of bed by 10-15 cm during sleep to prevent supine hypertension 1
• Medication review: Discontinue or modify medications that exacerbate orthostatic hypotension (psychotropic drugs, diuretics, α-adrenoreceptor antagonists) 1

Pharmacological Management

First-Line Medications:

1. Midodrine:

   • Peripheral selective α1-adrenergic agonist 1, 3
   • Dosing: Start at 2.5-5 mg three times daily 1, 3
   • Schedule: First dose before arising, last dose no later than 6 PM or at least 4 hours before bedtime 1, 3
   • Titration: Increase by 2.5 mg increments weekly to target dose of up to 10 mg three times daily 1
   • Maximum daily dose: 30-40 mg divided into 3-4 doses 1
   • Monitor for: Supine hypertension, pilomotor reactions, pruritus, bradycardia, GI symptoms, urinary retention 1, 3

2. Fludrocortisone:

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

Second-Line Medications:

1. Droxidopa:

   • Effective for neurogenic OH due to Parkinson's disease, pure autonomic failure, and multiple system atrophy 1

2. Pyridostigmine:

   • Consider for patients refractory to first-line treatments 1, 4

3. Erythropoietin:

   • For patients with hemoglobin levels <11 g/dL
   • Dosing: 25-75 U/kg three times weekly with a hemoglobin target of 12 g/dL 2

4. Other options:

   • Desmopressin acetate: Useful for nocturnal polyuria and morning orthostatic hypotension 2
   • Octreotide: For refractory recurrent postprandial or neurogenic OH 1
   • Somatostatin analogues: Inhibit release of vasoactive gastrointestinal peptides 2
   • Caffeine and acarbose: Help attenuate postprandial hypotension 2

Treatment Algorithm

1. Start with non-pharmacological approaches for all patients
2. If symptoms persist, add pharmacological therapy:
   • First-line: Midodrine or fludrocortisone (or combination for non-responders)
   • Second-line: Add droxidopa, pyridostigmine, or other agents for refractory cases
3. Continue medication only in patients reporting significant symptomatic improvement 3

Special Considerations

• Supine hypertension: Common complication of OH treatment; prevent by elevating head of bed and timing medication to avoid bedtime doses 1, 3
• Combination therapy: Monitor closely when combining midodrine and fludrocortisone due to increased risk of supine hypertension 1
• Renal impairment: Use midodrine with caution; start at lower dose (2.5 mg) 3
• Hemodialysis patients: Midodrine is removed by dialysis; adjust dosing accordingly 3
• Drug interactions: Avoid concomitant use of midodrine with MAO inhibitors, linezolid, or other vasoconstrictors 3

Remember that treatment should focus on improving symptoms and quality of life rather than normalizing blood pressure measurements 1.