How is orthostatic hypotension managed?

Management of Orthostatic Hypotension

Non-pharmacological interventions should be the first-line approach for all patients with orthostatic hypotension, followed by pharmacological therapy with droxidopa or midodrine for those with persistent symptoms. 1

Non-Pharmacological Management

Immediate Interventions

• Acute water ingestion: 500ml of water 30 minutes before meals or anticipated orthostatic stress
• Physical counter-pressure maneuvers: Leg crossing, squatting, and muscle tensing to prevent syncope
• Compression garments: Thigh-high compression stockings and abdominal binders providing 30-40 mmHg of pressure

Dietary Modifications

• Increase salt intake to 6-10g daily (approximately 1-2 teaspoons)
• Increase fluid intake to 2-3 liters per day
• Eat small, frequent meals (4-6 per day) instead of large meals
• Reduce carbohydrate content in meals
• Increase dietary fiber and protein content
• Avoid alcoholic beverages

Lifestyle Adjustments

• Regular exercise of leg and abdominal muscles (swimming is particularly beneficial)
• Use portable chairs when needed to prevent falls
• Avoid prolonged standing
• Rise slowly from supine or seated positions
• Elevate the head of the bed to prevent supine hypertension

Pharmacological Management

First-Line Medications

1. Droxidopa (100-600mg TID)

   • Strong recommendation with high-quality evidence
   • Last dose should be taken at least 3-4 hours before bedtime to minimize supine hypertension

2. Midodrine (5-20mg TID)

   • Strong recommendation with high-quality evidence
   • Alpha-1 adrenergic agonist that increases vascular tone
   • Last dose should be taken at least 3-4 hours before bedtime
   • Monitor for supine hypertension (BP>200 mmHg systolic) 2
   • Contraindicated in patients with severe cardiac disease, acute renal disease, urinary retention, pheochromocytoma, or thyrotoxicosis 2

Second-Line Medications

1. Fludrocortisone (0.1-0.3mg daily)

   • Moderate recommendation with lower quality evidence
   • Salt-retaining steroid that increases blood volume
   • Monitor for supine hypertension, edema, hypokalemia, and headache

2. Pyridostigmine (30mg 2-3 times daily)

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

3. Octreotide

   • Particularly beneficial for postprandial hypotension
   • Reduces splanchnic blood flow by approximately 20%
   • Consider for patients with refractory neurogenic OH

Monitoring and Follow-up

Blood Pressure Monitoring

• Check orthostatic blood pressure twice daily (supine and standing)
• Assess for supine hypertension (BP>180/110 mmHg)
• Evaluate treatment efficacy based on symptom improvement rather than absolute BP values

Additional Monitoring

• Daily weight to evaluate fluid status
• Regular electrolyte monitoring, particularly potassium and sodium
• Regular assessment of treatment efficacy and side effects

Special Populations

Elderly Patients

• Higher risk for postprandial hypotension, especially nursing home residents
• Start medications at lower doses and titrate slowly

Patients with Comorbidities

• Cardiac disease: Monitor closely for supine hypertension
• Diabetes with autonomic dysfunction: Focus on glucose control in addition to OH management
• Parkinson's disease: High risk for postprandial hypotension
• Heart failure: Start beta-blockers and ACE inhibitors/ARBs at very low doses
• Renal impairment: Use midodrine with caution, starting at 2.5mg 2

Common Pitfalls to Avoid

1. Focusing on BP numbers rather than symptoms

   • The goal is to reduce orthostatic symptoms and improve quality of life, not normalize BP

2. Overlooking non-pharmacological measures

   • Physical countermeasures and compression garments are highly effective and should always be implemented

3. Improper timing of medications

   • Administering vasopressors too close to bedtime increases the risk of supine hypertension

4. Failure to discontinue contributing medications

   • Review and adjust antihypertensives, antipsychotics, and diuretics when possible

5. Inadequate monitoring for supine hypertension

   • All pharmacological treatments can cause or worsen supine hypertension

By following this structured approach to managing orthostatic hypotension, clinicians can effectively improve patients' symptoms, reduce fall risk, and enhance quality of life while minimizing adverse effects such as supine hypertension.