From the Guidelines
Orthostatic hypotension should be managed with a combination of nonpharmacologic measures, such as ensuring adequate salt intake, avoiding medications that aggravate hypotension, and using compressive garments, along with pharmacologic measures, including midodrine and droxidopa, which are approved by the FDA for the treatment of orthostatic hypotension. To diagnose orthostatic hypotension, a thorough medical history and physical examination should be performed, including measuring blood pressure in both lying and standing positions.
Key Management Strategies
- Implementing lifestyle changes, such as rising slowly from seated or lying positions, staying well-hydrated with 2-3 liters of water daily, increasing salt intake (if not contraindicated by other conditions), wearing compression stockings, and avoiding alcohol and large meals.
- Using pharmacologic measures, such as midodrine (2.5-10mg three times daily, but not within 4 hours of bedtime to avoid supine hypertension) and droxidopa (100-600mg three times daily), which are approved by the FDA for the treatment of orthostatic hypotension 1.
- Regular monitoring of blood pressure in both lying and standing positions is essential to assess treatment effectiveness.
Additional Considerations
- Physical activity and exercise should be encouraged to avoid deconditioning, which is known to exacerbate orthostatic intolerance, and volume repletion with fluids and salt is critical 1.
- Supine blood pressure tends to be much higher in these patients, often requiring treatment of blood pressure at bedtime with shorter-acting drugs that also affect baroreceptor activity, such as guanfacine or clonidine, shorter-acting calcium blockers (e.g., isradipine), or shorter-acting β-blockers such as atenolol or metoprolol tartrate 1.
- Alternatives can include enalapril if patients are unable to tolerate preferred agents 1.
Patient-Specific Considerations
- For elderly patients or those with neurological conditions like Parkinson's disease who commonly experience this condition, a multifaceted approach combining lifestyle modifications and possibly medications offers the best management strategy.
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 diagnosis of orthostatic hypotension is not explicitly stated in the provided drug labels. The treatment for orthostatic hypotension includes:
- Midodrine hydrochloride tablets for symptomatic orthostatic hypotension
- Non-pharmacologic treatment, such as:
- Support stockings
- Fluid expansion
- Lifestyle alterations Midodrine should be used in patients whose lives are considerably impaired despite standard clinical care 2.
From the Research
Diagnosis of Orthostatic Hypotension
- Orthostatic hypotension is defined as a decrease in systolic blood pressure of 20 mm Hg or a decrease in diastolic blood pressure of 10 mm Hg within three minutes of standing when compared with blood pressure from the sitting or supine position 3.
- Common symptoms include dizziness, lightheadedness, blurred vision, weakness, fatigue, nausea, palpitations, and headache 3.
- Less common symptoms include syncope, dyspnea, chest pain, and neck and shoulder pain 3.
- Causes include dehydration or blood loss; disorders of the neurologic, cardiovascular, or endocrine systems; and several classes of medications 3.
Treatment of Orthostatic Hypotension
- Goals of treatment involve improving hypotension without excessive supine hypertension, relieving orthostatic symptoms, and improving standing time 3.
- Treatment includes correcting reversible causes and discontinuing responsible medications, when possible 3.
- Nonpharmacologic treatment should be offered to all patients, including optimizing blood volume, decreasing postural venous pooling, reducing heat and post-prandial induced vasodilation, emphasizing physical conditioning, and minimizing nocturnal diuresis 4.
- Pharmacologic therapies proven to be beneficial include fludrocortisone, midodrine, and pyridostigmine 3.
- First-line therapies are midodrine and fludrocortisone, which may need to be combined for optimal care of severe cases 5.
- Fludrocortisone is a mineralocorticoid that increases blood volume and blood pressure, and is considered the first- or second-line pharmacological therapy for orthostatic hypotension alongside mechanical and positional measures 6.
Non-Pharmacologic Measures
- Non-pharmacologic measures are aimed at optimizing blood volume, decreasing postural venous pooling, reducing heat and post-prandial induced vasodilation, emphasizing physical conditioning, and minimizing nocturnal diuresis 4.
- These measures may suffice in milder cases, but with more severe symptoms, such as falls, syncope or near-syncope, a pharmacological strategy is simultaneously employed 4.
- Most non-pharmacological measures are combined, and education of the patient is a cornerstone of treatment 5.
Pharmacologic Treatment
- Pharmacologic treatment should be individualized according to the severity, underlying cause, 24-hour blood pressure profile, and associated coexisting conditions 5.
- Common medications used in the treatment of OH include fludrocortisone, midodrine, pyridostigmine, and droxidopa 7.
- Only midodrine and droxidopa have received FDA approval for the treatment of orthostatic hypotension 7.
- Evidence on the effects of fludrocortisone on blood pressure, orthostatic symptoms or adverse events is very uncertain, and there is a need for standardized reporting of outcomes and for standardization of measurements of blood pressure in orthostatic hypotension 6.