What is the treatment for orthostatic hypotension?

Treatment of Orthostatic Hypotension

The treatment of orthostatic hypotension should follow a stepwise approach, starting with non-pharmacological measures, followed by medication adjustments and pharmacological interventions with midodrine as first-line pharmacological treatment for persistent symptoms. 1

Non-Pharmacological Interventions (First-Line)

Non-pharmacological measures should be implemented for all patients with orthostatic hypotension:

• Fluid and Salt Intake:

  • Increase fluid intake to 2-3 liters per day 1
  • Increase salt intake to 10g of NaCl daily (if not contraindicated) 1
  • Acute water ingestion (480 mL) for immediate temporary relief 1

• Physical Countermeasures:

  • 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

• Dietary Modifications:

  • Small, frequent meals with reduced carbohydrate content to minimize postprandial hypotension 1
  • Limit alcohol consumption 2

• Exercise:

  • Regular exercise, especially swimming and leg/abdominal muscle exercises 1

Medication Review and Adjustment

Identify and reduce/discontinue medications that may cause or worsen hypotension 1:

• Diuretics
• Vasodilators
• Alpha-blockers
• Antipsychotics (especially quetiapine which has high risk of orthostatic hypotension)
• Beta-blockers

Pharmacological Interventions

When non-pharmacological measures are insufficient:

First-Line Medications:

• Midodrine:

  • Starting dose: 5-10 mg three times daily
  • Maximum dose: 10 mg three times daily 1
  • FDA-approved for symptomatic orthostatic hypotension in patients whose lives are considerably impaired despite standard clinical care 3
  • Caution: Can cause marked elevation of supine blood pressure (>200 mmHg systolic) 3
  • Should be continued only for patients who report significant symptomatic improvement 3

• Droxidopa:

  • Starting dose: 100 mg three times daily 1
  • FDA-approved for treatment of orthostatic dizziness and lightheadedness in adult patients with symptomatic neurogenic orthostatic hypotension 4
  • Particularly effective for reducing falls in neurogenic orthostatic hypotension 1
  • Note: Effectiveness beyond 2 weeks of treatment has not been established; continued effectiveness should be assessed periodically 4

Second-Line Medications:

• Fludrocortisone:

  • Starting dose: 0.05-0.1 mg daily
  • Titration dose: 0.1-0.3 mg daily as needed 1
  • Monitor for supine hypertension and serum potassium levels 1

• Pyridostigmine:

  • Dose: 30 mg 2-3 times daily
  • Useful for patients refractory to other treatments 1

• Additional Options for Specific Situations:

  • Desmopressin: For nocturnal polyuria 1
  • Erythropoietin: For patients with anemia (Hb <11 g/dL), 25-75 U/kg three times weekly 1

Treatment Approach Based on Severity

• Mild OH: Non-pharmacological measures alone
• Moderate OH: Non-pharmacological measures plus medication review and adjustment
• Severe OH: Aggressive non-pharmacological measures plus pharmacological treatment (midodrine first-line) 1

Special Populations Considerations

• Diabetic Patients:

  • Focus on glucose control to prevent worsening autonomic symptoms
  • Monitor for exaggerated hypotensive responses to medications 1

• Heart Failure Patients:

  • Start beta-blockers and ACE inhibitors/ARBs at very low doses 1

• Elderly Patients (≥85 years) or Frail:

  • Consider long-acting dihydropyridine CCBs or RAS inhibitors as initial therapy
  • Add low-dose diuretics if tolerated 1

• Pregnant Patients:

  • Volume expansion with intravenous fluids for acute management
  • Position change to left lateral decubitus position for symptomatic episodes 1

Monitoring and Follow-up

• Regular blood pressure monitoring in both supine and standing positions
• Follow-up within 1-2 weeks for symptomatic patients
• Monitor for supine hypertension and adjust treatment accordingly 1
• Assess treatment efficacy and side effects regularly to adjust treatment as needed 1

Common Pitfalls and Caveats

• Supine Hypertension: Many treatments for orthostatic hypotension can worsen supine hypertension, requiring careful blood pressure monitoring and medication timing
• Medication Overtreatment: Continue pharmacological treatments only in patients who show symptomatic improvement 3
• Inadequate Non-pharmacological Measures: Always emphasize and optimize non-pharmacological approaches before advancing to medications
• Failure to Address Underlying Causes: Identify and treat reversible causes before initiating symptomatic therapy