What are the treatment options for orthostatic hypotension?

Treatment Options for Orthostatic Hypotension

The management of orthostatic hypotension requires a comprehensive approach combining non-pharmacological interventions as first-line therapy, followed by pharmacological options for patients with persistent symptoms, with midodrine being the most evidence-supported medication for symptomatic orthostatic hypotension. 1, 2

Non-Pharmacological Interventions (First-Line)

Fluid and Salt Management

• Maintain fluid intake of 2-3L per day 1
• Increase salt intake to 6-10g daily (unless contraindicated) 1
• Rapid cool water ingestion (500ml, 30 minutes before anticipated orthostatic stress) 1

Physical Countermeasures

• Physical counterpressure maneuvers: leg crossing, squatting, muscle tensing 1
• Compression garments:
  • Abdominal binders
  • Thigh-high compression stockings (30-40 mmHg pressure) - most effective when applied before rising 1
• Head-up tilt sleeping (10° elevation) to prevent nocturnal polyuria and maintain better fluid distribution 1
• Regular exercise of leg and abdominal muscles (especially swimming) to prevent deconditioning 1

Dietary Modifications

• Small, frequent meals (4-6 per day) 1
• Reduce carbohydrate content 1
• Increase dietary fiber and protein content 1
• Avoid alcoholic beverages 1

Pharmacological Interventions

First-Line Medications

1. Midodrine (5-20mg three times daily)

   • Alpha-1 agonist that increases vascular tone
   • Increases standing systolic BP by 15-30 mmHg within 1 hour
   • Last dose should be taken no later than 6 PM to avoid supine hypertension
   • FDA-approved specifically for symptomatic orthostatic hypotension
   • Caution: Can cause marked elevation of supine blood pressure (>200 mmHg systolic) 1, 2

2. Fludrocortisone (0.1-0.3mg once daily)

   • Mineralocorticoid that stimulates renal sodium retention and expands fluid volume
   • Particularly effective when combined with increased salt intake 1

Second-Line Medications

1. Droxidopa (100-600mg TID)

   • Strongly recommended with high-quality evidence for neurogenic orthostatic hypotension 1

2. Pyridostigmine (30mg 2-3 times daily)

   • May be considered for patients refractory to other treatments 1

3. Octreotide

   • Beneficial in patients with refractory neurogenic OH
   • Particularly effective for postprandial hypotension 1

4. Acarbosa

   • Alpha-glucosidase inhibitor that helps control postprandial hypotension
   • Delays carbohydrate absorption and reduces release of vasoactive gastrointestinal peptides 1

Monitoring and Treatment Evaluation

• Regular BP measurements in both supine and standing positions 1
• Evaluate treatment efficacy based on symptom improvement rather than absolute BP values 1
• Monitor for supine hypertension (BP >180/110 mmHg) 1, 2
• Daily weight assessment and regular electrolyte monitoring 1

Special Considerations

Medication Interactions

• Use caution when combining with:
  • Cardiac glycosides (risk of bradycardia, AV block)
  • Other vasoconstrictors (phenylephrine, ephedrine, etc.)
  • MAO inhibitors or linezolid
  • Alpha-adrenergic blocking agents (prazosin, terazosin, doxazosin) 2

Special Populations

• Pregnant patients: Volume expansion with IV fluids; position change to left lateral decubitus 1
• Diabetic patients: Focus on glucose control 1
• Heart failure patients: Start beta-blockers and ACE inhibitors/ARBs at very low doses 1
• Patients with renal impairment: Use midodrine with caution, starting at 2.5mg 2
• Patients with hepatic impairment: Use midodrine with caution 2

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
• Inadequate monitoring for supine hypertension 1
• Continuing midodrine in patients who don't report significant symptomatic improvement 2