What medications are used to treat orthostatic (postural) hypotension?

Medications for Orthostatic Hypotension

For symptomatic orthostatic hypotension, first-line pharmacological treatments include fludrocortisone, midodrine, and droxidopa, with selection based on the underlying cause and patient characteristics. 1, 2

First-Line Pharmacological Options

Fludrocortisone

• Mechanism: Mineralocorticoid that increases plasma volume
• Dosing: Start low (typically 0.1mg daily) and titrate as needed
• Best for: Patients with neurogenic orthostatic hypotension, especially when combined with increased salt intake
• Limitations: May cause supine hypertension, edema, hypokalemia, and headache
• Contraindications: Heart failure, uncontrolled hypertension, chronic kidney disease 2

Midodrine

• Mechanism: Alpha-1 agonist that increases vascular tone
• Dosing: 5-20mg three times daily (last dose no later than 6 PM)
• Best for: Symptomatic orthostatic hypotension refractory to non-pharmacological measures
• Effects: Increases standing systolic BP by 15-30 mmHg within 1 hour
• Limitations: Can cause marked supine hypertension (BP>200 mmHg systolic)
• FDA indication: For symptomatic orthostatic hypotension in patients whose lives are considerably impaired despite standard clinical care 3

Droxidopa

• Mechanism: Norepinephrine precursor
• Dosing: 100-600mg three times daily
• Best for: Neurogenic orthostatic hypotension
• Limitations: May cause supine hypertension, headache, dizziness, and nausea 1, 2

Second-Line Options

Pyridostigmine

• Mechanism: Acetylcholinesterase inhibitor that enhances sympathetic ganglionic transmission
• Dosing: 30mg 2-3 times daily
• Best for: Patients with orthostatic hypotension refractory to other treatments
• Side effects: Nausea, vomiting, abdominal cramping, sweating, salivation, and urinary incontinence 1, 2

Octreotide

• Mechanism: Reduces splanchnic blood flow by approximately 20%
• Best for: Patients with refractory recurrent postprandial or neurogenic orthostatic hypotension
• Effect: Prevents postprandial hypotension, increases blood pressure, and improves orthostatic tolerance 1, 2

Treatment Algorithm

1. Confirm diagnosis: Drop in BP ≥20/10 mmHg within 3 minutes of standing

2. Start with non-pharmacological measures:

   • Increased salt (6-9g daily) and fluid intake (2-3L/day)
   • Physical counterpressure maneuvers
   • Compression stockings (30-40 mmHg pressure, thigh-high)
   • Head-up tilt sleeping (10° elevation)
   • Small, frequent meals with reduced carbohydrate content

3. If symptoms persist, initiate pharmacotherapy based on cause:

   • For peripheral sympathetic denervation: Droxidopa or midodrine
   • For central autonomic dysfunction: Norepinephrine reuptake inhibitors
   • For volume depletion: Fludrocortisone with increased salt intake

4. For postprandial hypotension: Consider acarbose or octreotide

Monitoring and Precautions

• Monitor for supine hypertension: Measure BP in both supine and standing positions
• Timing of medications: Last dose of midodrine or droxidopa should be taken at least 3-4 hours before bedtime
• Electrolyte monitoring: Regular assessment of sodium and potassium levels, especially with fludrocortisone
• Drug interactions: Use caution when combining with other vasoconstrictors, cardiac glycosides, or medications that affect heart rate 2, 3

Special Considerations

• Elderly patients: Start with lower doses and monitor closely for supine hypertension
• Diabetic patients: Focus on glucose control alongside orthostatic hypotension management
• Heart failure patients: Use volume-expanding agents with extreme caution; consider starting with very low doses of beta-blockers
• Renal impairment: Use midodrine with caution; start with lower dose (2.5mg) 3

Remember that the goal of treatment is to improve symptoms and quality of life rather than to normalize blood pressure readings 4. Evaluate treatment efficacy based on symptom improvement rather than absolute BP values.