What are the treatment options for orthostatic (postural) hypotension?

Treatment Options for Orthostatic Hypotension

Non-pharmacological interventions should be the first-line approach for orthostatic hypotension management, followed by pharmacological options only when symptoms significantly impair daily activities despite conservative measures. 1

Non-Pharmacological Management

Lifestyle Modifications

• Increase salt intake (2-2.5 liters per day) unless contraindicated 1
• Increase fluid intake (drinking 480 mL of water can acutely raise blood pressure) 1
• Eat small, frequent meals with reduced carbohydrate content to minimize postprandial hypotension 1
• Avoid prolonged standing and use portable chairs when needed 1
• Elevate head of bed by 10-15 cm during sleep to prevent supine hypertension 1

Physical Countermeasures

• Use compression garments for legs and abdomen to reduce gravitational pooling 1
• Implement physical counter-maneuvers such as leg crossing, muscle tensing, and squatting 1
• Engage in regular exercise, especially swimming and leg/abdominal muscle exercises 1

Pharmacological Management

First-Line Medications

1. Midodrine

   • FDA-approved for symptomatic orthostatic hypotension 2
   • Dosing: Start at 2.5-5 mg three times daily, titrate up to 10 mg TID 1
   • Caution: Can cause marked elevation of supine blood pressure (>200 mmHg systolic) 2
   • Should only be continued in patients who report significant symptomatic improvement 2
   • Take last dose at least 3-4 hours before bedtime to avoid supine hypertension 1

2. Fludrocortisone

   • Dosing: Start at 0.05-0.1 mg daily, titrate to 0.1-0.3 mg daily 1
   • Monitor for fluid retention, hypokalemia, and worsening supine hypertension 1

3. Droxidopa

   • FDA-approved alternative to midodrine, particularly effective for neurogenic orthostatic hypotension 1, 3
   • Clinical trials showed significant improvement in dizziness scores at Week 1 3
   • Effectiveness beyond 2 weeks is uncertain; patients should be evaluated periodically 3
   • Take last dose at least 3 hours before bedtime to reduce risk of supine hypertension 3

Second-Line Medications

• Pyridostigmine for patients refractory to other treatments 1, 4
• Octreotide for patients refractory to other treatments 1
• Erythropoietin for patients with hemoglobin levels under 11 g/dL (25-75 U/kg three times weekly) 1

Treatment Algorithm

1. Review and modify medications that may worsen orthostatic hypotension (diuretics, vasodilators, antidepressants, alpha-blockers) 1, 5

2. Implement non-pharmacological measures for all patients 1, 5

3. Add pharmacological therapy if symptoms persist and significantly impact quality of life:

   • For mild to moderate symptoms: Start with fludrocortisone 1
   • For more severe symptoms (especially neurogenic OH): Consider midodrine or droxidopa 1, 2, 3
   • For refractory cases: Consider combination therapy or second-line agents 1

4. Monitor treatment efficacy by:

   • Improvement in symptoms (dizziness, lightheadedness, syncope)
   • Reduction in falls
   • Increased standing time
   • Improved ability to perform daily activities 1, 5

Special Considerations

• Supine hypertension: Common complication of OH treatment. Use shorter-acting agents during daytime hours and avoid taking medications before bedtime 1, 3

• Heart failure patients: Start beta-blockers and ACE inhibitors/ARBs at very low doses and titrate gradually 1

• Elderly patients: Consider long-acting dihydropyridine CCBs or RAS inhibitors as initial therapy 1

• Treatment goals: Focus on improving symptoms and functional status, reducing falls and syncope, increasing standing time, and balancing treatment with prevention of excessive supine hypertension 1

Common Pitfalls to Avoid

1. Continuing medications without documented symptomatic improvement 2, 3
2. Not monitoring for supine hypertension, especially at night 1, 3
3. Aggressive pharmacological treatment before optimizing non-pharmacological measures 1, 5
4. Overlooking medication side effects (midodrine: supine hypertension; fludrocortisone: fluid retention) 1
5. Not evaluating the continued effectiveness of droxidopa beyond 2 weeks 3