What are the management guidelines for postural hypotension?

Management of Postural Hypotension

The management of postural hypotension should prioritize non-pharmacological measures first, followed by pharmacological interventions when symptoms persist, with the goal of minimizing postural symptoms rather than restoring normotension. 1

Non-Pharmacological Measures (First-Line)

Volume Expansion and Dietary Modifications

• Increase salt intake to 6-10g daily (approximately 1-2 teaspoons) 1
• Increase fluid intake to 2-3 liters per day 1
• Acute water ingestion (500ml, 30 minutes before meals or anticipated orthostatic stress) 1
• Eat small, frequent meals (4-6 per day) instead of large meals 1
• Reduce carbohydrate content and increase fiber and protein in meals 1
• Avoid alcoholic beverages 1

Physical Countermeasures

• Physical counter-pressure maneuvers (leg crossing, squatting, muscle tensing) 1, 2
• Compression garments (thigh-high compression stockings, abdominal binders) providing at least 30-40 mmHg of pressure 1
• Regular exercise of leg and abdominal muscles, especially swimming 1
• Avoid deconditioning through regular physical activity 3

Pharmacological Measures (Second-Line)

When non-pharmacological measures are insufficient, consider medications in the following order:

1. Droxidopa (100-600mg TID) - FDA-approved for neurogenic orthostatic hypotension with strong evidence 1, 4

   • Effectiveness beyond 2 weeks is uncertain; patients should be evaluated periodically 4

2. Midodrine (5-20mg TID) - FDA-approved for symptomatic orthostatic hypotension 1, 5

   • Should only be continued in patients who report significant symptomatic improvement 5

3. Fludrocortisone (0.1-0.3mg daily) - Salt-retaining steroid 1, 6

   • Monitor for supine hypertension, edema, hypokalemia, and headache 1

4. Pyridostigmine (30mg 2-3 times daily) - For patients refractory to other treatments 1

5. Octreotide - Particularly beneficial for postprandial hypotension 1

Monitoring and Management

• Regular blood pressure monitoring in both supine and standing positions 1
• Assess treatment efficacy based on symptom improvement rather than absolute BP values 1
• Monitor for supine hypertension (BP>180/110 mmHg) 1
• For patients on fludrocortisone, monitor serum potassium levels 1
• Evaluate daily weight to assess fluid status 1

Special Considerations

Diabetic Patients

• Focus on glucose control in addition to standard measures 1
• Consider withdrawing medications that affect gastrointestinal motility, including GLP-1 RAs and DPP-4 inhibitors 3

Elderly Patients

• May require treatment of supine blood pressure at bedtime with shorter-acting drugs 3
• Options include:
  • Shorter-acting drugs affecting baroreceptor activity (guanfacine, clonidine)
  • Shorter-acting calcium blockers (e.g., isradipine)
  • Shorter-acting β-blockers (atenolol, metoprolol tartrate)
  • Enalapril as an alternative if patients cannot tolerate preferred agents 3

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
• Adding salt to water may paradoxically reduce the pressor response compared to water alone 7

Diagnosis Reminder

Orthostatic hypotension is defined as a drop in systolic BP of ≥20 mmHg or diastolic BP of ≥10 mmHg within 3 minutes of assuming upright posture 3, 6.

The clearest signs following excessive blood loss are a large postural pulse change (30 beats per minute) or severe postural dizziness leading to lack of ability to stand 3.