What are the treatment options for orthostatic hypotension?

Treatment of Orthostatic Hypotension

Droxidopa (100-600mg TID) or midodrine (5-20mg TID) are strongly recommended as first-line pharmacological treatments for symptomatic orthostatic hypotension when non-pharmacological measures are insufficient. 1

Treatment Algorithm

Step 1: Non-Pharmacological Interventions (First-Line)

• Acute water ingestion: 500ml, 30 minutes before meals or anticipated orthostatic stress 1
• Physical counter-maneuvers: Leg crossing, squatting, muscle tensing 1
• Compression garments: Thigh-high compression stockings or abdominal binders (30-40 mmHg pressure) 1
• Dietary modifications:
  • Increased salt intake: 6-10g daily 1
  • Small, frequent meals (4-6 per day) instead of large meals 1
  • Reduced carbohydrate content in meals 1
  • Increased dietary fiber and protein 1
  • Avoiding alcoholic beverages 1
  • Increased fluid intake to 2-3 liters per day 1
• Regular exercise of leg and abdominal muscles, especially swimming 1
• Portable chairs when needed to prevent falls 1

Step 2: Pharmacological Interventions (When Non-Pharmacological Measures Are Insufficient)

First-Line Medications:

• Droxidopa: 100-600mg TID (strong recommendation, high-quality evidence) 1
• Midodrine: 5-20mg TID (strong recommendation, high-quality evidence) 1, 2
  • FDA-approved specifically for symptomatic orthostatic hypotension
  • Use only in patients whose lives are considerably impaired despite standard clinical care

Second-Line Medications:

• Fludrocortisone: 0.1-0.3mg daily (moderate recommendation, lower quality evidence) 1
  • Monitor for supine hypertension, edema, hypokalemia, and headache

Third-Line/Refractory Cases:

• Pyridostigmine: 30mg 2-3 times daily 1
• Octreotide: Particularly beneficial for postprandial hypotension 1
• Atomoxetine: Consider in elderly patients who fail other therapies 3

Monitoring and Management

• Assess treatment efficacy based on symptom improvement rather than absolute BP values 1
• Monitor orthostatic blood pressure twice daily 1
• Regular assessment for supine hypertension (BP>180/110 mmHg) 1
• For patients on fludrocortisone, monitor serum potassium levels 1
• Daily weight assessment to evaluate fluid status 1

Special Considerations

High-Risk Populations:

• Elderly patients: Particularly nursing home residents 1
• Patients with autonomic dysfunction: Including diabetic autonomic neuropathy 1
• Parkinson's disease patients 1
• Post-bariatric surgery patients 1
• Pregnant patients: Manage with volume expansion and left lateral decubitus positioning 1
• Heart failure patients: Start beta-blockers and ACE inhibitors/ARBs at very low doses 1

Common Pitfalls to Avoid

• Focusing on BP numbers rather than symptoms 1
• Overlooking non-pharmacological measures 1
• Improper timing of medications (administering vasopressors too close to bedtime) 1
• Failure to discontinue contributing medications (antihypertensives, antipsychotics, diuretics) 1
• Inadequate monitoring for supine hypertension 1

Treatment Sequence

1. Review and modify/remove medications that may cause or worsen OH 4
2. Implement non-pharmacological measures 4
3. Add pharmacological measures if symptoms persist 4
4. Consider combination treatments for refractory cases 4

The goal of treatment is to improve orthostatic symptoms, increase standing time, and enhance quality of life, not necessarily to normalize blood pressure values 1, 5.