What is the diagnosis and treatment for orthostatic hypotension?

From the Guidelines

Orthostatic hypotension should be managed with a combination of non-pharmacological and pharmacological approaches, prioritizing the most recent and highest quality evidence, which recommends midodrine and droxidopa as first-line treatments, as stated in the 2022 guidelines 1.

Diagnosis and Treatment

Orthostatic hypotension is a condition characterized by a sudden drop in blood pressure when changing positions, typically from lying down to sitting or standing. It occurs when the body's compensatory mechanisms fail to maintain adequate blood pressure during positional changes. Symptoms include dizziness, lightheadedness, blurred vision, weakness, and occasionally fainting.

Non-Pharmacological Approaches

Management begins with non-pharmacological approaches such as:

• Rising slowly from lying or sitting positions
• Staying well-hydrated (aiming for 2-3 liters of fluid daily)
• Increasing salt intake (if not contraindicated by other conditions)
• Wearing compression stockings
• Avoiding alcohol and large meals

Pharmacological Approaches

If these measures are insufficient, medications may be necessary. The most recent guidelines recommend:

• Midodrine (2.5-10 mg three times daily) to constrict blood vessels and raise blood pressure
• Droxidopa (100-600 mg three times daily) as an alternative for neurogenic orthostatic hypotension Other options, such as fludrocortisone, may be considered, but the evidence is less strong, as noted in the 2017 guidelines 1.

Monitoring and Precautions

Blood pressure should be monitored regularly, especially when starting new treatments, and patients should be cautious about activities that might exacerbate symptoms, such as hot showers or prolonged standing. It is also essential to identify and address underlying causes, such as dehydration, anemia, or medication side effects, as emphasized in the 2021 guidelines 1.

From the FDA Drug Label

Midodrine hydrochloride tablets are indicated for the treatment of symptomatic orthostatic hypotension (OH) Because midodrine hydrochloride tablets can cause marked elevation of supine blood pressure (BP>200 mmHg systolic), it should be used in patients whose lives are considerably impaired despite standard clinical care, including non-pharmacologic treatment (such as support stockings), fluid expansion, and lifestyle alterations

The diagnosis of orthostatic hypotension is not explicitly stated in the provided drug labels, but it is implied to be a condition characterized by a significant drop in blood pressure when standing up, resulting in symptoms such as dizziness or lightheadedness. The treatment for orthostatic hypotension includes:

• Non-pharmacologic treatment:
  • Support stockings
  • Fluid expansion
  • Lifestyle alterations
• Pharmacologic treatment: Midodrine hydrochloride tablets, which can cause marked elevation of supine blood pressure, and should be used in patients whose lives are considerably impaired despite standard clinical care 2.

From the Research

Diagnosis of Orthostatic Hypotension

• Orthostatic hypotension is defined as a fall in systolic blood pressure greater than 20 mm Hg or a fall in diastolic blood pressure greater than 10 mm Hg within 3 minutes of standing 3, 4
• Symptoms include light headedness, weakness, blurred vision, fatigue, lethargy, and falls 3
• Diagnosis is based on the history and a thorough clinical examination, with further testing of the heart, kidneys, and autonomic nervous system may be required in selected patients 3

Treatment of Orthostatic Hypotension

• Non-pharmacologic strategies include:
  • Avoiding large carbohydrate-rich meals
  • Limiting alcohol consumption
  • Maintaining adequate hydration
  • Adding salt to foods
  • Using compression stockings, tilt-table exercises, or abdominal binders 5
  • Slow position change
  • Increased fluid and sodium intake
  • Elevation of head of the bed 3, 6
• Pharmacological treatment options include:
  • Fludrocortisone 5, 3, 7, 4
  • Midodrine 5, 3, 4
  • Pyridostigmine 5, 7
  • Droxidopa 5
  • Pseudoephedrine 5
  • Octreotide 5, 3
  • Atomoxetine 5
• Treatment should be individualized according to the severity, underlying cause, 24-hour blood pressure profile, and associated coexisting conditions 4
• First-line therapies are midodrine and fludrocortisone, which may need to be combined for optimal care of severe cases 4