What are the treatment options for orthostatic hypotension?

Treatment Options for Orthostatic Hypotension

The most effective treatment approach for orthostatic hypotension combines non-pharmacological measures as first-line therapy, followed by pharmacological interventions with droxidopa or midodrine for patients with persistent symptoms. 1

Non-Pharmacological Measures (First-Line Treatment)

Lifestyle Modifications

• Fluid and Salt Intake:
  • Increase fluid intake to 2-3 liters per day 1
  • Increase salt intake to 6-10g daily (1-2 teaspoons) 1
  • Acute water ingestion (500ml, 30 minutes before meals or anticipated orthostatic stress) for temporary symptom relief 1

Physical Countermeasures

• Physical counter-pressure maneuvers (leg crossing, squatting, muscle tensing) to prevent syncope 1
• Regular exercise of leg and abdominal muscles, especially swimming 1
• Using portable chairs when needed to prevent falls 1

Compression Garments

• Thigh-high compression stockings providing 30-40 mmHg of pressure 1
• Abdominal binders to reduce venous pooling 1

Dietary Modifications

• Eat small, frequent meals (4-6 per day) instead of large meals 1
• Reduce carbohydrate content in meals 1
• Increase dietary fiber and protein content 1
• Avoid alcoholic beverages 1

Pharmacological Measures (Second-Line Treatment)

First-Choice Medications

• Droxidopa (100-600mg TID): Strongly recommended with high-quality evidence 1
• Midodrine (5-20mg TID): Strongly recommended with high-quality evidence 1, 2
  • Acts via alpha-1 adrenergic receptors to increase vascular tone 2
  • Last dose should be taken 3-4 hours before bedtime to minimize supine hypertension 2
  • Contraindicated in patients with severe cardiac disease, acute renal disease, urinary retention, pheochromocytoma, or thyrotoxicosis 2

Alternative Medications

• Fludrocortisone (0.1-0.3mg daily): Moderate recommendation with lower quality evidence 1
  • Monitor for supine hypertension, edema, hypokalemia, and headache 1
• Pyridostigmine (30mg 2-3 times daily): Consider for patients refractory to other treatments 1
• Octreotide: Beneficial in patients with refractory neurogenic OH, particularly for postprandial hypotension 1

Monitoring and Management

Blood Pressure Monitoring

• Regular BP monitoring in both supine and standing positions 1
• Monitor for supine hypertension (BP>180/110 mmHg) 1
• Assess treatment efficacy based on symptom improvement rather than absolute BP values 1

Medication Monitoring

• For patients on fludrocortisone, monitor serum potassium levels 1
• For patients on midodrine, monitor for signs of supine hypertension (BP>200 mmHg systolic) 2
• Regularly assess treatment efficacy and side effects to adjust treatment accordingly 1

Special Considerations

Cardiac Disease

• Monitor closely for supine hypertension 1
• Use caution with cardiac glycosides when administering midodrine (may enhance bradycardia) 2

Elderly Patients

• Particularly nursing home residents are at high risk for postprandial hypotension 1
• Start with lower doses of medications and titrate slowly 1

Autonomic Dysfunction

• Patients with diabetic autonomic neuropathy require additional interventions 1
• Focus on glucose control in diabetic patients 1

Heart Failure

• Prioritize beta-blockers and ACE inhibitors/ARBs but start at very low doses 1

Common Pitfalls to Avoid

• Focusing on BP numbers rather than symptoms: The goal is to reduce orthostatic symptoms and improve quality of life, not normalize BP 1
• Overlooking non-pharmacological measures: These are highly effective and should always be implemented before or alongside pharmacological treatment 1
• Improper timing of medications: Administering vasopressors too close to bedtime increases the risk of supine hypertension 1, 2
• Failure to discontinue contributing medications: Antihypertensives, antipsychotics, and diuretics can worsen orthostatic hypotension 1
• Inadequate monitoring for supine hypertension: All pharmacological treatments can cause or worsen supine hypertension 1, 2

Treatment Algorithm

1. Start with comprehensive non-pharmacological measures
2. If symptoms persist, add pharmacological therapy:
   • First-line: Droxidopa or Midodrine
   • Second-line: Fludrocortisone
   • Third-line: Pyridostigmine or Octreotide
3. Adjust treatment based on symptom improvement and side effects
4. Continue to monitor for supine hypertension and other adverse effects