What are the treatment options for orthostatic hypotension?

Treatment Options for Orthostatic Hypotension

The first-line treatment for orthostatic hypotension should include non-pharmacological interventions, followed by pharmacological options such as midodrine (5-20mg three times daily) or fludrocortisone (0.1-0.3mg daily) when symptoms persist despite conservative measures. 1

Non-Pharmacological Interventions

Non-pharmacological measures should be implemented before considering medication:

• Increased salt intake: 6-10g daily (1-2 teaspoons) unless contraindicated 1
• Acute water ingestion: 500ml, 30 minutes before meals or anticipated orthostatic stress 1
• Physical counter-pressure maneuvers: leg crossing, squatting, and muscle tensing 1
• Compression garments: thigh-high compression stockings and abdominal binders providing 30-40 mmHg of pressure 1
• Regular exercise: particularly of leg and abdominal muscles (swimming is especially beneficial) 1
• Dietary modifications:
  • Small, frequent meals (4-6 per day)
  • Reduced carbohydrate content
  • Increased dietary fiber and protein
  • Avoiding alcoholic beverages 1

Pharmacological Interventions

When non-pharmacological measures are insufficient, medications should be considered:

First-Line Medications:

1. Midodrine (5-20mg three times daily):

   • Alpha-1 agonist that increases vascular tone
   • Elevates standing systolic BP by 15-30 mmHg within 1 hour
   • Effects persist for 2-3 hours
   • Last dose should be taken 3-4 hours before bedtime to minimize supine hypertension 1, 2

2. Fludrocortisone (0.1-0.3mg daily):

   • Increases sodium retention and volume expansion
   • Requires regular monitoring of electrolytes, particularly potassium 1

Second-Line Medications:

1. Droxidopa (100-600mg TID):

   • Strongly recommended for neurogenic orthostatic hypotension 1

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

   • May be considered for patients refractory to other treatments 1

3. Octreotide:

   • Particularly beneficial for postprandial hypotension
   • Consider in patients with refractory neurogenic OH 1

Special Considerations

Monitoring

• Evaluate treatment efficacy based on symptom improvement rather than absolute BP values 1
• Monitor for supine hypertension (BP>180/110 mmHg) 1, 2
• Check orthostatic BP twice daily 1
• Assess daily weight to evaluate fluid status 1
• Monitor electrolytes regularly, especially in patients taking fludrocortisone 1

Cautions

• Supine hypertension: All pharmacological treatments can cause or worsen this condition 1, 2
• Medication timing: Avoid administering vasopressors close to bedtime 1, 2
• Drug interactions: Use midodrine cautiously with:
  • Cardiac glycosides (may cause bradycardia)
  • Other vasoconstrictors (phenylephrine, ephedrine)
  • MAO inhibitors
  • Alpha-blockers (antagonize midodrine's effects) 2

Special Populations

• Elderly: Higher risk (20% prevalence), require slow titration and fall monitoring 1
• Cardiac disease: Monitor closely for supine hypertension 1
• Diabetes: Focus on glucose control in addition to OH management 1
• Renal impairment: Start midodrine at lower dose (2.5mg) 2
• Urinary retention: Use midodrine cautiously as it affects bladder neck 2

Common Pitfalls to Avoid

• Focusing on BP numbers rather than symptom improvement 1
• Overlooking non-pharmacological measures 1
• Improper timing of medications (especially too close to bedtime) 1, 2
• Failure to discontinue contributing medications (antihypertensives, antipsychotics, diuretics) 1
• Inadequate monitoring for supine hypertension 1, 2

Remember that the goal of treatment is to improve functional capacity and quality of life rather than achieving specific BP targets 3. The treatment approach should prioritize symptom management while minimizing the risk of supine hypertension.