What are the treatment options for orthostatic (postural) hypotension?

From the Guidelines

Treatment for orthostatic hypotension should focus on both non-pharmacological and pharmacological approaches, with the goal of minimizing postural symptoms rather than restoring normotension, as stated in the 2022 guidelines 1. The therapeutic approach to orthostatic hypotension involves a combination of non-pharmacologic measures, such as ensuring adequate salt intake, avoiding medications that aggravate hypotension, using compressive garments over the legs and abdomen, and pharmacologic measures.

• Non-pharmacological measures include:
  • Increasing fluid intake to 2-3 liters daily and salt consumption to 8-10 grams per day, unless contraindicated by other conditions
  • Physical countermeasures like standing up slowly, avoiding prolonged standing, performing leg muscle contractions before standing, and using compression stockings
  • Elevating the head of the bed by 4-6 inches to reduce nocturnal diuresis and morning hypotension
• Pharmacological measures include:
  • Midodrine (ProAmatine) 2.5-10 mg three times daily, an alpha-1 agonist that increases vascular tone, with the last dose taken at least 4 hours before bedtime to avoid supine hypertension
  • Droxidopa (Northera) 100-600 mg three times daily, which can be effective for neurogenic orthostatic hypotension
  • Fludrocortisone (Florinef) 0.1-0.3 mg daily, which increases sodium retention and blood volume
  • Pyridostigmine 30-60 mg three times daily, which may benefit patients with autonomic failure These medications work by either expanding blood volume or increasing peripheral vascular resistance to maintain blood pressure upon standing, as recommended in the 2017 guidelines 1. The most recent and highest quality study, published in 2022, recommends a combination of non-pharmacologic and pharmacologic measures to minimize postural symptoms and improve quality of life in patients with orthostatic hypotension 1. It is essential to individualize treatment based on symptom severity, underlying causes, and comorbidities, and to monitor patients closely for potential side effects and interactions. The 2009 guidelines also support the use of adequate hydration, salt intake, midodrine, fludrocortisone, and physical counterpressure maneuvers in the treatment of orthostatic hypotension 1. However, the 2022 guidelines provide the most up-to-date and comprehensive recommendations for the management of orthostatic hypotension, and should be prioritized in clinical practice.

From the FDA Drug Label

Midodrine hydrochloride tablets are indicated for the treatment of symptomatic orthostatic hypotension (OH) Because midodrine hydrochloride tablets can cause marked elevation of supine blood pressure (BP>200 mmHg systolic), it should be used in patients whose lives are considerably impaired despite standard clinical care, including non-pharmacologic treatment (such as support stockings), fluid expansion, and lifestyle alterations

The treatment options for orthostatic (postural) hypotension include:

• Midodrine hydrochloride tablets for patients with symptomatic orthostatic hypotension
• Non-pharmacologic treatment, such as:
  • Support stockings
  • Fluid expansion
  • Lifestyle alterations These options should be considered for patients whose lives are considerably impaired despite standard clinical care 2

From the Research

Treatment Options for Orthostatic Hypotension

The treatment options for orthostatic hypotension can be categorized into non-pharmacologic and pharmacologic measures.

• Non-pharmacologic measures include:
  • Reviewing and modifying medications that may aggravate or cause orthostatic hypotension 3
  • Optimizing blood volume, decreasing postural venous pooling, reducing heat and post-prandial induced vasodilation, emphasizing physical conditioning, and minimizing nocturnal diuresis 3
  • Avoiding large carbohydrate-rich meals, limiting alcohol consumption, maintaining adequate hydration, adding salt to foods, and using compression stockings, tilt-table exercises, or abdominal binders 4
• Pharmacologic measures include:
  • Fludrocortisone, which is considered a first- or second-line pharmacological therapy for orthostatic hypotension 5
  • Midodrine and droxidopa, which have a strong recommendation level for pharmacological treatment of neurogenic orthostatic hypotension 6
  • Atomoxetine, which has been shown to be effective in improving symptoms and blood pressure control in elderly patients with primary orthostatic hypotension 4
  • Other alternative agents, such as pyridostigmine, yohimbine, fluoxetine, ergot alkaloids, ephedrine, phenylpropanolamine, octreotide, indomethacin, ibuprofen, caffeine, methylphenidate, and desmopressin, which have a weak recommendation and low or very low quality of evidence 6

Sequential Steps for Management

The management of orthostatic hypotension can be outlined in 4 sequential steps:

• Review medications and modify or remove those that may aggravate or cause orthostatic hypotension 3
• Non-pharmacologic measures 3
• Pharmacologic measures 3, 7
• Treatment combinations 3

Special Considerations

In cases of severe postprandial hypotension, acarbose and octreotide are recommended with a strong recommendation and moderate level of evidence 6. Alternatively, voglibose or caffeine may be useful, but with a weak recommendation 6.