What is the best management approach for a patient with both hypertension and orthostatic hypotension?

Management of Hypertension with Orthostatic Hypotension

For patients with both hypertension and orthostatic hypotension, non-pharmacological approaches should be the first-line treatment, followed by careful medication selection that minimizes orthostatic effects rather than simply reducing antihypertensive therapy. 1

Initial Assessment

• Test for orthostatic hypotension before starting or intensifying BP-lowering medication by:
  • Having patient sit or lie for 5 minutes
  • Measuring BP at 1 and 3 minutes after standing 1
• Define orthostatic hypotension as a decrease in systolic BP ≥20 mmHg or diastolic BP ≥10 mmHg within 3 minutes of standing 2, 3

Non-Pharmacological Management (First-Line)

1. Lifestyle modifications:

   • Increased salt intake (6-9g daily) unless contraindicated 4
   • Small, frequent meals to reduce postprandial hypotension 4
   • Adequate hydration with acute water ingestion (≥240 mL) 30 minutes before standing 4
   • Elevate head of bed by 10° to prevent nocturnal polyuria and reduce supine hypertension 4

2. Physical countermeasures:

   • Compression garments (thigh-high or abdominal) 4
   • Physical counter-pressure maneuvers (leg crossing, muscle tensing) 4

Pharmacological Management

For Hypertension Control:

1. Preferred agents in patients with orthostatic hypotension:

   • Long-acting dihydropyridine calcium channel blockers (CCBs) 1, 5
   • Renin-angiotensin system (RAS) inhibitors 1, 5

2. Medication timing:

   • Consider short-acting antihypertensives at bedtime for severe supine hypertension 4
   • Avoid nighttime dosing of long-acting agents that may worsen morning orthostatic symptoms

3. Medications to avoid or use with caution:

   • Beta-blockers (unless compelling indications exist) 1
   • Alpha-blockers 1
   • Diuretics (use low doses if necessary) 1

For Orthostatic Hypotension:

1. First-line pharmacological options:

   • Midodrine 5-20 mg three times daily (last dose before 6 PM) 4, 6
     • Caution: Can cause marked supine hypertension (monitor BP) 6
     • Starting dose 2.5 mg in renal impairment 6

2. Alternative options:

   • Fludrocortisone 0.1-0.3 mg daily 4
     • Monitor for worsening supine hypertension
     • May need to reduce dose when used with antihypertensives 6

Medication Adjustment Strategy

1. For patients with uncontrolled hypertension and orthostatic hypotension:

   • Switch BP-lowering medications that worsen orthostatic hypotension to alternative therapies rather than simply reducing doses 1
   • Consider SGLT2 inhibitors in patients with CKD (eGFR >20 mL/min/1.73 m²) for modest BP lowering 1

2. For severe supine hypertension with orthostatic hypotension:

   • Use short-acting antihypertensives at bedtime 4
   • Aim for "as low as reasonably achievable" (ALARA) systolic BP if target of 120-129 mmHg is not tolerable 1

Monitoring

• Regular orthostatic BP measurements to assess treatment efficacy
• Consider ambulatory BP monitoring to identify abnormal diurnal patterns 4
• Monitor for supine hypertension, especially with pressor medications 4, 6
• Evaluate treatment based on symptom improvement rather than BP normalization 4

Special Considerations

• In elderly patients (≥85 years) or those with frailty, use long-acting dihydropyridine CCBs or RAS inhibitors as first-line agents 1
• Review medications that may cause or worsen orthostatic hypotension (e.g., tamsulosin, sildenafil, trazodone, carvedilol) 5
• Maintain BP-lowering treatment lifelong if well tolerated, even beyond age 85 1

Common Pitfalls to Avoid

1. Simply reducing antihypertensive medication doses without addressing orthostatic hypotension specifically
2. Focusing solely on BP numbers rather than symptom improvement
3. Failing to test for orthostatic hypotension before medication adjustments
4. Administering pressor medications like midodrine too late in the day (can cause dangerous supine hypertension)
5. Overlooking non-pharmacological measures, which should be first-line therapy

By following this approach, both conditions can be effectively managed while minimizing risks of falls, syncope, and cardiovascular events.