How is orthostatic hypotension managed?

Management of Orthostatic Hypotension

The management of orthostatic hypotension should follow a stepwise approach, beginning with non-pharmacological interventions as first-line treatment, followed by pharmacological options for patients with persistent symptoms, with midodrine being the most strongly recommended medication for symptomatic orthostatic hypotension. 1

Diagnosis and Assessment

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

Non-Pharmacological Management (First-Line)

1. Dietary Modifications:

   • Increase salt intake (6-10g daily, 1-2 teaspoons) unless contraindicated 1
   • Consume small, frequent meals (4-6 per day) to reduce postprandial hypotension 1
   • Reduce carbohydrate content and increase dietary fiber and protein 1
   • Avoid alcoholic beverages 1
   • Acute water ingestion (500ml, 30 minutes before meals or anticipated orthostatic stress) 1

2. Physical Measures:

   • Compression garments (thigh-high compression stockings, abdominal binders) providing 30-40 mmHg of pressure 1, 2
   • Physical counter-pressure maneuvers (leg crossing, squatting, muscle tensing) 1
   • Regular exercise of leg and abdominal muscles, especially swimming 1
   • Orthostatic training for younger patients 1

3. Lifestyle Modifications:

   • Elevate head of bed to prevent supine hypertension 3
   • Avoid prolonged standing
   • Avoid hot environments (showers, baths, saunas)
   • Position change to left lateral decubitus position for symptomatic episodes (especially in pregnant patients) 1

Pharmacological Management (Second-Line)

1. Midodrine (First-line pharmacological option):

   • Dosage: 5-20mg three times daily 1, 3
   • Indications: Symptomatic orthostatic hypotension refractory to non-pharmacological measures 3
   • Timing: Last dose should be taken 3-4 hours before bedtime to minimize nighttime supine hypertension 3
   • Contraindications: Severe supine hypertension, urinary retention, severe cardiac disease 3
   • Monitoring: Blood pressure in supine and standing positions 3

2. Droxidopa:

   • Dosage: 100-600mg three times daily 1
   • Strongly recommended for neurogenic orthostatic hypotension 1
   • Similar precautions regarding timing as midodrine

3. Fludrocortisone:

   • Dosage: 0.1-0.3mg daily 1
   • May be considered in younger patients with orthostatic vasovagal syncope 1
   • Requires monitoring of serum potassium levels and daily weight 1
   • Has concerning long-term effects 4

4. Other Options:

   • Pyridostigmine (30mg 2-3 times daily) for refractory cases 1
   • Octreotide for refractory neurogenic OH, particularly for postprandial hypotension 1

Special Patient Populations

1. Elderly Patients:

   • Higher risk (20% prevalence) 1
   • More prone to medication side effects 1
   • Require slow titration approach and regular monitoring for falls 1

2. Patients with Cardiac Disease:

   • Monitor closely for supine hypertension 1
   • Use caution with cardiac glycosides 3
   • For heart failure patients, prioritize beta-blockers and ACE inhibitors/ARBs but start at very low doses 1

3. Diabetic Patients:

   • Focus on glucose control 1
   • Additional interventions may be required for autonomic dysfunction 1
   • Use midodrine with caution 3

4. Patients with Renal Impairment:

   • Start midodrine at lower dose (2.5mg) 3
   • Assess renal function prior to initiating therapy 3

Medication Review and Adjustment

• Identify and discontinue contributing medications when possible:
  • Antihypertensives
  • Antipsychotics (especially quetiapine - high risk; aripiprazole - preferred option with lower risk) 1
  • Diuretics
  • Vasodilators
  • MAO inhibitors 3
  • Alpha-adrenergic blocking agents (prazosin, terazosin, doxazosin) 3

Common Pitfalls to Avoid

1. Focusing on BP numbers rather than symptoms - The goal is to improve quality of life, not normalize BP 1

2. Overlooking non-pharmacological measures - These should always be implemented before or alongside medications 1

3. Improper timing of medications - Administering vasopressors too close to bedtime increases risk of supine hypertension 1, 3

4. Inadequate monitoring for supine hypertension - All pharmacological treatments can cause or worsen this condition 1, 3

5. Failure to discontinue contributing medications - Review and adjust medications that may exacerbate orthostatic hypotension 1

The management of orthostatic hypotension requires balancing the improvement of standing BP to minimize symptoms without generating excessive supine hypertension 5. Regular assessment of treatment efficacy and side effects is necessary to adjust treatment accordingly 1.