What are the treatment options for orthostatic hypotension?

Treatment Options for Orthostatic Hypotension

The first-line approach to orthostatic hypotension should include non-pharmacological interventions, with midodrine (5-20mg three times daily) as the primary pharmacological treatment for symptomatic patients whose lives are considerably impaired despite standard clinical care. 1, 2

Non-Pharmacological Interventions

Immediate Measures

• 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 at least 30-40 mmHg of pressure 1

Lifestyle Modifications

• Exercise: Regular exercise of leg and abdominal muscles, especially swimming 1
• Dietary modifications for postprandial hypotension:
  • Small, frequent meals (4-6 per day)
  • Reduced carbohydrate content
  • Increased dietary fiber and protein
  • Avoiding alcoholic beverages 1

Pharmacological Interventions

First-Line Medications

• Midodrine (5-20mg three times daily):

  • FDA-approved for symptomatic orthostatic hypotension
  • Alpha-1 agonist that increases vascular tone
  • Last dose should be taken 3-4 hours before bedtime to avoid supine hypertension
  • Monitor for supine hypertension (BP>200 mmHg systolic) 1, 2

• Fludrocortisone (0.1-0.3mg daily):

  • Increases sodium retention and volume expansion
  • Monitor for electrolyte imbalances, particularly potassium 1

Second-Line Medications

• Droxidopa (100-600mg TID):

  • Strongly recommended for neurogenic orthostatic hypotension 1

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

  • Consider for patients refractory to other treatments 1

• Octreotide:

  • Particularly beneficial for postprandial hypotension 1

Treatment Algorithm

1. Start with non-pharmacological measures:

   • Increased salt and water intake
   • Compression garments
   • Physical counter-maneuvers
   • Dietary modifications

2. If symptoms persist, add pharmacological therapy:

   • First-line: Midodrine (starting at 5mg TID, titrate up to 20mg TID as needed)
   • Alternative first-line: Fludrocortisone (0.1mg daily, titrate up to 0.3mg as needed)

3. For refractory cases:

   • Add droxidopa (100mg TID, titrate up to 600mg TID)
   • Consider pyridostigmine or octreotide for specific cases

Special Considerations

Medication Timing

• Administer midodrine with the last dose no later than 6 PM or 3-4 hours before bedtime 1, 2
• Time medications to cover periods of anticipated orthostatic stress

Monitoring

• Evaluate treatment efficacy based on symptom improvement rather than absolute BP values 1
• Monitor for supine hypertension (BP>180/110 mmHg) 1
• Check orthostatic BP twice daily 1
• Regular electrolyte monitoring, particularly for patients on fludrocortisone 1

Cautions

• Supine hypertension: All pharmacological treatments can cause or worsen this condition 1, 2
• Drug interactions: Use caution when combining midodrine with:
  • Cardiac glycosides (risk of bradycardia)
  • Other vasoconstrictors (phenylephrine, ephedrine)
  • MAO inhibitors
  • Alpha-adrenergic blockers 2

Special Populations

• Elderly: Higher risk (20% prevalence), require slow titration 1
• Cardiac disease: Monitor closely for supine hypertension 1
• Renal impairment: Use midodrine with caution, starting at 2.5mg 2
• Diabetic patients: Focus on glucose control in addition to OH management 1
• Heart failure: Start beta-blockers and ACE inhibitors/ARBs at very low doses 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 (antihypertensives, antipsychotics, diuretics) 1
• Inadequate monitoring for supine hypertension 1, 2