How to manage orthostatic hypotension?

Management of Orthostatic Hypotension

First-line treatment for orthostatic hypotension should include dietary modifications, increased salt and fluid intake, and physical counter-maneuvers, with medications such as midodrine, fludrocortisone, and acarbose reserved for refractory cases. 1

Non-Pharmacological Management

Dietary Modifications

• Eat small, frequent meals (4-6 per day) instead of large meals
• Reduce carbohydrate content in meals
• Delay fluid intake until at least 30 minutes after meals
• Increase dietary fiber and protein content
• Avoid alcoholic beverages

Fluid and Salt Intake

• Increase salt intake to 6-10g daily (approximately 1-2 teaspoons)
• Increase fluid intake to 2-3 liters per day
• Drink water 30 minutes before meals for pressor effect
• Note: Interestingly, water alone may provide a better pressor response than salt water in some patients 2

Physical Counter-Maneuvers

• Use compression garments (thigh-high compression stockings and abdominal binders)
• Implement physical counter-pressure maneuvers:
  • Leg crossing
  • Squatting
  • Muscle tensing
• Regular exercise of leg and abdominal muscles, especially swimming
• Use portable chairs when needed to prevent falls

Pharmacological Management

First-Line Medications

• Midodrine (5-20mg three times daily)

  • Alpha-1 adrenergic agonist
  • FDA-approved for symptomatic orthostatic hypotension 3
  • Take last dose 3-4 hours before bedtime to avoid supine hypertension
  • Monitor for supine hypertension (BP>200 mmHg systolic)
  • Contraindicated in patients with severe cardiac disease, acute renal failure, urinary retention, pheochromocytoma, or thyrotoxicosis 3

• Fludrocortisone (0.1-0.3mg daily)

  • Salt-retaining steroid
  • Monitor for supine hypertension, edema, hypokalemia, and headache

Second-Line Medications

• Droxidopa

  • Recommended for neurogenic orthostatic hypotension

• Pyridostigmine (30mg 2-3 times daily)

  • Improves orthostatic tolerance by increasing peripheral vascular resistance
  • Consider for patients refractory to other treatments

Treatment Algorithm

1. Initial Management:

   • Identify and correct reversible causes (dehydration, medication effects)
   • Discontinue or modify medications that worsen orthostatic hypotension:
     • Antihypertensives
     • Alpha-blockers (tamsulosin)
     • Vasodilators (sildenafil)
     • Some antidepressants (trazodone)
     • Beta-blockers (carvedilol)

2. Non-pharmacological interventions:

   • Implement all dietary modifications, salt/fluid intake, and physical counter-maneuvers

3. If symptoms persist, add pharmacological therapy:

   • Start with midodrine 5mg three times daily (last dose at least 4 hours before bedtime)
   • Titrate up to 10-20mg three times daily as needed
   • OR start fludrocortisone 0.1mg daily, increase to 0.3mg if needed

4. For refractory cases:

   • Consider combination therapy
   • Add pyridostigmine 30mg 2-3 times daily
   • Consider specialist referral

Special Populations

Hypertensive Patients with OH

• Angiotensin receptor blockers and calcium channel blockers are preferred antihypertensives 4
• For isolated supine hypertension, use short-acting antihypertensives at bedtime

Elderly and Frail Patients

• Start medications at lower doses
• Monitor closely for adverse effects
• Consider long-acting dihydropyridine CCBs or RAS inhibitors as initial therapy

Patients with Autonomic Dysfunction

• More aggressive management may be needed
• Consider earlier initiation of pharmacological therapy

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
• Monitor serum potassium levels when using fludrocortisone
• Daily weight assessment to evaluate fluid status

Common Pitfalls and Caveats

• Failure to recognize drug-induced orthostatic hypotension
• Inadequate monitoring for supine hypertension with treatment
• Overtreatment leading to supine hypertension
• Undertreatment of symptomatic orthostatic hypotension
• Taking midodrine too close to bedtime (should be at least 3-4 hours before)
• Not considering postprandial hypotension as a cause of symptoms

Remember that the goal of treatment is to improve orthostatic tolerance without causing excessive supine hypertension, relieve orthostatic symptoms, and improve standing time and quality of life.