What are the treatment options for orthostatic hypotension?

Management of Orthostatic Hypotension

The most effective treatment approach for orthostatic hypotension includes both non-pharmacological measures (increased salt intake, physical counter-pressure maneuvers, compression garments) and pharmacological options (midodrine, fludrocortisone, droxidopa) tailored to symptom severity and underlying cause. 1

Initial Assessment and Diagnosis

• Orthostatic hypotension is defined as a decrease in systolic BP ≥20 mmHg or diastolic BP ≥10 mmHg within 3 minutes of standing
• Regular BP monitoring in both supine and standing positions is essential
• Focus on symptom improvement rather than absolute BP values when assessing treatment efficacy 1
• Monitor for supine hypertension (BP>180/110 mmHg), a common complication of treatment

Non-Pharmacological Management (First-Line)

All patients should receive these interventions before or alongside pharmacological treatment:

1. Salt and Fluid Management:

   • Increased salt intake of 6-10g daily (1-2 teaspoons) unless contraindicated 1
   • Acute water ingestion (500ml, 30 minutes before meals or anticipated orthostatic stress) 1

2. Physical Countermeasures:

   • Leg crossing, squatting, and muscle tensing to prevent syncope 1
   • Regular exercise of leg and abdominal muscles, especially swimming 1

3. Compression Garments:

   • Thigh-high compression stockings or abdominal binders providing 30-40 mmHg of pressure 1

4. Dietary Modifications:

   • Small, frequent meals (4-6 per day) with reduced carbohydrate content
   • Increased dietary fiber and protein content
   • Avoid alcoholic beverages 1

5. Positional Changes:

   • Sleep with head of bed elevated to prevent supine hypertension 2
   • Slow, gradual position changes from lying to sitting to standing

Pharmacological Management

When non-pharmacological measures are insufficient, medications should be considered based on symptom severity and underlying cause:

First-Line Medications:

1. Midodrine (5-20mg TID):

   • Strong recommendation for symptomatic orthostatic hypotension 1
   • FDA-approved for treatment of symptomatic orthostatic hypotension 2
   • Take last dose 3-4 hours before bedtime to minimize nighttime supine hypertension 2
   • Contraindications: severe cardiac disease, acute kidney injury, urinary retention, pheochromocytoma 2
   • Monitor for supine hypertension, urinary retention, and bradycardia 2

2. Droxidopa (100-600mg TID):

   • Strong recommendation for neurogenic orthostatic hypotension 1, 3
   • Similar precautions regarding timing of doses to avoid supine hypertension

Second-Line Medications:

1. Fludrocortisone (0.1-0.3mg daily):

   • Moderate recommendation for orthostatic hypotension, especially in younger patients 1
   • Increases blood volume through sodium and water retention 4
   • Monitor for hypokalemia, edema, and worsening of supine hypertension 1
   • Evidence for long-term efficacy is limited 4

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

   • Consider for patients refractory to other treatments 1
   • May be particularly useful in Parkinson's disease 4

3. Octreotide:

   • Beneficial for refractory neurogenic OH and postprandial hypotension 1, 3
   • Strong recommendation for severe postprandial hypotension 3

Special Patient Populations

1. Elderly Patients:

   • Higher risk (20% prevalence) and more prone to medication side effects 1
   • Use slow titration approach and monitor closely for falls and fractures
   • Particularly at risk for postprandial hypotension

2. Patients with Parkinson's Disease:

   • High risk for postprandial hypotension 1
   • May benefit from droxidopa or midodrine

3. Diabetic Patients with Autonomic Dysfunction:

   • Focus on glucose control alongside OH management 1
   • Additional monitoring for peripheral neuropathy complications

4. Heart Failure Patients:

   • Start beta-blockers and ACE inhibitors/ARBs at very low doses 1
   • Monitor closely for worsening orthostatic symptoms

Medication Management

• Review and adjust contributing medications:

  • Antihypertensives (especially alpha-blockers)
  • Antipsychotics (quetiapine has high risk, aripiprazole preferred) 1
  • Tricyclic antidepressants
  • Diuretics
  • MAO inhibitors 2, 5

• Avoid drug interactions:

  • Use caution when combining midodrine with other vasoconstrictors (phenylephrine, ephedrine) 2
  • Monitor closely when using with cardiac glycosides or beta-blockers 2

Monitoring and Follow-up

• Assess treatment efficacy based on symptom improvement rather than absolute BP values 1
• Monitor for supine hypertension with all pharmacological treatments
• For patients on fludrocortisone, regularly check serum potassium levels 1
• Daily weight assessment to evaluate fluid status
• Regular electrolyte monitoring, particularly potassium and sodium 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 1
• Inadequate monitoring for supine hypertension 1