What are the initial management steps for a patient with orthostatic hypotension?

Initial Management of Orthostatic Hypotension

The first therapeutic approach for orthostatic hypotension should include exclusion of medications that exacerbate the condition, correction of volume depletion, and implementation of non-pharmacological measures before initiating pharmacological therapy. 1, 2

Diagnosis and Assessment

• Orthostatic hypotension is defined as a decrease in systolic blood pressure ≥20 mmHg or diastolic blood pressure ≥10 mmHg within 3 minutes of standing compared to sitting or supine position 2
• Testing should be performed by having the patient sit or lie for 5 minutes, then measuring BP at 1 and/or 3 minutes after standing 1, 2
• Document heart rate response to standing to assess baroreflex function 3
• Common symptoms include dizziness, lightheadedness, blurred vision, weakness, fatigue, and syncope 4

Step 1: Medication Review and Modification

• Identify and discontinue or modify medications that may cause or worsen orthostatic hypotension 2, 5:
  • Antihypertensives (especially alpha-blockers)
  • Diuretics
  • Vasodilators
  • Psychotropic medications
  • Cardiac glycosides
  • MAO inhibitors
  • Sedatives
  • Prostate-specific alpha-blockers

Step 2: Non-Pharmacological Interventions

• Increase fluid intake (480 mL of water acutely can raise blood pressure) 2, 6
• Increase salt intake (unless contraindicated) 2
• Avoid large carbohydrate-rich meals and alcohol 2
• Implement physical counter-pressure maneuvers 2:
  • Leg crossing
  • Muscle tensing
  • Squatting
• Use compression garments for lower extremities and abdomen 2, 6
• Elevate head of bed by 10-15 cm during sleep to prevent supine hypertension 2
• Practice gradual staged movements when changing positions 2
• Avoid prolonged standing 4
• Consider smaller, more frequent meals to reduce postprandial hypotension 2, 6

Step 3: Pharmacological Therapy

If symptoms persist despite non-pharmacological measures, consider medication therapy:

1. Midodrine (first-line) 1, 2, 7:

   • Starting dose: 2.5-5 mg three times daily
   • Target dose: up to 10 mg three times daily
   • Maximum daily dose: 30-40 mg divided into 3-4 doses
   • Last dose should be taken 3-4 hours before bedtime to minimize supine hypertension
   • Monitor for adverse effects: supine hypertension, piloerection, pruritus, urinary retention

2. Fludrocortisone (first-line alternative) 1, 2:

   • Starting dose: 0.05-0.1 mg daily
   • Target dose: 0.1-0.3 mg daily
   • Monitor for adverse effects: supine hypertension, hypokalemia, edema, congestive heart failure

3. Combination therapy may be considered for non-responders to monotherapy 1, 2

4. Alternative agents for refractory cases 2:

   • Droxidopa (especially for neurogenic OH)
   • Pyridostigmine
   • Octreotide (for postprandial hypotension)
   • Erythropoietin (if hemoglobin <11 g/dL)

Special Considerations

• For patients with diabetes and orthostatic hypotension, use medications cautiously 7
• For elderly patients (≥85 years) or those with frailty, consider long-acting dihydropyridine CCBs or RAS inhibitors as initial therapy, followed by low-dose diuretics if tolerated 1
• For patients with renal impairment, use midodrine with caution, starting at 2.5 mg 7
• Continue medications only in patients who report significant symptomatic improvement 7
• Monitor for supine hypertension, especially with pharmacological therapy 7

Treatment Goals

• Improve symptoms and functional status
• Reduce risk of falls and syncope
• Increase standing time and ability to perform daily activities
• Balance treatment of OH with prevention of excessive supine hypertension 3, 4