What are the treatment options for recurrent orthostatic hypotension?

Treatment Options for Recurrent Orthostatic Hypotension

The first-line approach for recurrent orthostatic hypotension should include non-pharmacological measures, followed by midodrine (starting at 5-10 mg three times daily) as the primary pharmacological intervention for persistent symptoms. 1

Non-Pharmacological Interventions

Fluid and Salt Management

• Increase fluid intake to 2-3 liters per day 1
• Increase salt intake to 10g of NaCl daily (if not contraindicated by hypertension, renal disease, or heart failure) 2, 1
• Acute water ingestion (480 mL) can provide immediate temporary relief 1
• Fluid resuscitation via oral or intravenous bolus for acute dehydration 2

Physical Measures

• Compression garments (thigh-high compression stockings and abdominal binders) 1
• Physical counter-pressure maneuvers (leg crossing, squatting, muscle tensing) 1
• Elevate head of bed by 10° during sleep to prevent nocturnal polyuria 1
• Regular exercise, especially swimming and leg/abdominal muscle exercises 1

Dietary Adjustments

• Eat small, frequent meals with reduced carbohydrate content to minimize postprandial hypotension 1

Medication Review

• Identify and reduce/discontinue medications that may cause or worsen hypotension 2, 1:
  • Diuretics
  • Vasodilators
  • Alpha-blockers
  • Antipsychotics
  • Beta-blockers

Pharmacological Interventions

First-Line Medications

1. Midodrine

   • Starting dose: 5-10 mg three times daily 1, 3
   • Maximum dose: 10 mg three times daily 3
   • Take last dose 3-4 hours before bedtime to minimize supine hypertension 3
   • Monitor for supine hypertension (BP >200 mmHg systolic) 3
   • FDA-approved specifically for symptomatic orthostatic hypotension 3

2. Fludrocortisone

   • Starting dose: 0.05-0.1 mg daily 1
   • Titration dose: 0.1-0.3 mg daily as needed 2, 1
   • Monitor for supine hypertension, edema, hypokalemia, and headache 2
   • Avoid as first choice when supine hypertension is present 2

Second-Line Medications

1. Droxidopa

   • Starting dose: 100 mg three times daily 1
   • Can reduce falls in neurogenic orthostatic hypotension 1
   • May be limited by supine hypertension, headache, dizziness, and nausea 2

2. Pyridostigmine

   • Dose: 30 mg 2-3 times daily 1
   • Beneficial in patients refractory to other treatments 2, 1
   • Side effects include nausea, vomiting, abdominal cramping, sweating 2

3. Octreotide

   • Beneficial for refractory recurrent postprandial or neurogenic OH 2
   • Reduces splanchnic blood flow by approximately 20% 2

Special Considerations

Diabetic Patients

• Focus on glucose control to prevent worsening autonomic symptoms 1
• Monitor for exaggerated hypotensive responses to medications 1
• May require additional interventions before discharge 1

Elderly Patients

• Consider starting with lower doses of medications 1
• Monitor more closely for side effects 1
• May have multiple comorbidities requiring careful medication management 2

Monitoring and Follow-up

• Regular blood pressure monitoring in both supine and standing positions 1
• Follow-up within 1-2 weeks for symptomatic patients 1
• Monitor for supine hypertension and adjust treatment accordingly 3
• Monitor serum potassium levels when using fludrocortisone 1

Treatment Algorithm

1. Start with non-pharmacological measures for all patients
2. Review and adjust current medications that may worsen OH
3. If symptoms persist:
   • For mild OH: Continue non-pharmacological measures
   • For moderate OH: Add midodrine (first-line) or fludrocortisone
   • For severe OH: Aggressive non-pharmacological measures plus midodrine, consider adding second-line agents if inadequate response

Cautions

• Supine hypertension is a common side effect of pharmacological treatment 3
• Midodrine should be used cautiously in patients with urinary retention problems 3
• Fludrocortisone doses >0.3 mg daily can cause adrenal and immunosuppression 2
• Monitor for cardiac effects when using midodrine with cardiac glycosides 3

Remember that the goal of treatment is to improve symptoms and functional capacity rather than achieving specific blood pressure targets 4. The treatment approach should balance improving orthostatic symptoms while minimizing supine hypertension.