Treatment of Orthostatic Hypotension
Adequate hydration and salt intake must be maintained as the foundation of orthostatic hypotension treatment, with midodrine as the first-line pharmacological intervention for symptomatic patients whose lives are considerably impaired despite standard clinical care. 1, 2
Non-Pharmacological Interventions (First-Line)
Volume Expansion Strategies
- Increased salt intake: 6-10g daily (1-2 teaspoons) unless contraindicated 3
- Fluid intake: Target 2-3L of fluids per day 1
- Rapid cool water ingestion: 500ml, 30 minutes before meals or anticipated orthostatic stress 3
Mechanical Countermeasures
- Compression garments: Abdominal binders or thigh-high compression stockings (30-40 mmHg pressure) to reduce venous pooling 1, 3
- Physical counterpressure maneuvers (PCMs): Leg crossing, squatting, and muscle tensing for patients with warning symptoms 1, 3
- Head-up tilt sleeping: Elevate head of bed by 10° to prevent nocturnal polyuria, maintain better fluid distribution, and ameliorate nocturnal hypertension 1
Lifestyle Modifications
- Dietary modifications: Small, frequent meals (4-6 per day), reduced carbohydrate content, increased dietary fiber and protein 3
- Exercise: Regular exercise of leg and abdominal muscles, especially swimming, to prevent deconditioning 3
- Alcohol avoidance: Particularly important for patients with postprandial hypotension 3
Pharmacological Interventions
First-Line Medications
Midodrine: 5-20mg three times daily (only FDA-approved medication specifically for symptomatic orthostatic hypotension) 1, 3, 2
- Administer during daytime hours when upright
- Last dose should be at least 4 hours before bedtime to avoid supine hypertension
- Monitor for supine hypertension (BP >200 mmHg systolic)
Fludrocortisone: 0.1-0.3mg once daily (mineralocorticoid that stimulates renal sodium retention) 1, 3
- Monitor for fluid retention, hypokalemia, and supine hypertension
- Particularly useful when combined with increased salt intake
Second-Line Medications
- Droxidopa: 100-600mg three times daily for neurogenic orthostatic hypotension 3
- Pyridostigmine: 30mg 2-3 times daily for refractory cases 3
- Octreotide: For postprandial hypotension, particularly in patients with autonomic failure 3
- Acarbose: For postprandial hypotension, especially in diabetic patients with autonomic neuropathy 3
- Erythropoietin: Consider in patients with anemia (Hb <11 g/dL) 3
Treatment Algorithm
Initial approach: Start with non-pharmacological measures
- Adequate hydration and salt intake
- Compression garments
- Physical countermeasure techniques
- Head-up tilt sleeping
If symptoms persist: Add pharmacological therapy
- First-line: Midodrine (5-20mg TID) or Fludrocortisone (0.1-0.3mg daily)
- Second-line: Consider adding Droxidopa, Pyridostigmine, or other agents based on specific clinical features
For specific presentations:
- Postprandial hypotension: Add Acarbose or Octreotide
- Anemia: Consider Erythropoietin
- Nocturnal polyuria: Add Desmopressin
Monitoring and Evaluation
- Regular blood pressure measurements in both supine and standing positions
- Monitor for supine hypertension (BP >180/110 mmHg)
- Evaluate treatment efficacy based on symptom improvement rather than absolute BP values
- Daily weight assessment to evaluate fluid status
- Regular electrolyte monitoring, particularly potassium and sodium
Important Considerations
- Drug-induced orthostasis: Elimination of offending agents is the principal treatment strategy 1
- Supine hypertension risk: All pharmacological treatments can cause or worsen supine hypertension 3
- Focus on symptoms: The goal is to reduce orthostatic symptoms and improve quality of life, not normalize BP 3
- Special populations: Elderly patients, those with cardiac disease, and patients with autonomic dysfunction require special consideration 3
By implementing this comprehensive approach to orthostatic hypotension management, clinicians can effectively improve symptoms and quality of life for affected patients while minimizing risks of treatment.