How do I treat a patient with orthostatic hypotension?

From the Guidelines

To treat a patient with orthostatic hypotension, first ensure adequate hydration and consider non-pharmacologic measures such as compression garments, physical counter-pressure maneuvers, and increased salt and fluid intake, and for persistent symptoms, pharmacologic options like midodrine, droxidopa, or fludrocortisone may be beneficial, as recommended by the 2017 ACC/AHA/HRS guideline 1. The treatment of orthostatic hypotension involves a multi-faceted approach, including non-pharmacologic and pharmacologic interventions.

• Non-pharmacologic measures include:
  • Ensuring adequate hydration by encouraging oral fluid intake of 2-3 liters daily
  • Using compression garments, such as thigh-high compression stockings, to reduce venous pooling
  • Implementing physical counter-pressure maneuvers, like leg crossing or squatting, to increase blood pressure
  • Increasing salt and fluid intake to expand plasma volume
• Pharmacologic options, as recommended by the 2017 ACC/AHA/HRS guideline 1, include:
  • Midodrine (2.5-10 mg three times daily) as a vasoconstrictor
  • Droxidopa (100-600 mg three times daily) to increase norepinephrine levels
  • Fludrocortisone (0.1-0.2 mg daily) to increase sodium retention and blood volume It is essential to note that the treatment should be individualized, and the choice of intervention should be based on the patient's specific needs and medical history, as well as the underlying cause of orthostatic hypotension. Additionally, other studies, such as the 2021 standards of medical care in diabetes 1 and the 2009 guidelines for the diagnosis and management of syncope 1, also support the use of these interventions, but the 2017 ACC/AHA/HRS guideline 1 provides the most comprehensive and up-to-date recommendations. The 2018 standards of medical care in diabetes 1 also emphasize the importance of addressing orthostatic hypotension, but the 2017 ACC/AHA/HRS guideline 1 is more specific and detailed in its recommendations. Overall, the treatment of orthostatic hypotension requires a careful and individualized approach, taking into account the patient's specific needs and medical history, as well as the underlying cause of the condition.

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 treatment for a patient with orthostatic hypotension involves the use of midodrine hydrochloride tablets, but only in patients whose lives are considerably impaired despite standard clinical care.

• Non-pharmacologic treatment options, such as support stockings, fluid expansion, and lifestyle alterations, should be considered first.
• Midodrine should be used with caution, as it can cause marked elevation of supine blood pressure.
• Patients should be evaluated for supine hypertension at the beginning of midodrine therapy and monitored closely for symptoms. 2

From the Research

Diagnosis and Definition

• Orthostatic hypotension is defined as a fall in systolic blood pressure greater than 20 mm Hg or a fall in diastolic blood pressure greater than 10 mm Hg within 3 minutes of standing 3, 4
• Symptoms include light headedness, weakness, blurred vision, fatigue and lethargy, and falls 3

Treatment Approaches

• Non-pharmacological methods are the key to management of orthostatic hypotension, including:
  • Slow position change 3, 4
  • Increased fluid and sodium intake 3, 4
  • Compression stockings 3
  • Elevation of head of the bed 3, 5
• Pharmacological treatment with:
  • Fludrocortisone 3, 4, 6
  • Midodrine 3, 4, 7
• Other drugs like desmopresin acetate, xamoterol, erythropoetin, and ocreotide can be used as second-line agents in selected patients 3

Pharmacological Treatment

• Fludrocortisone is considered the first- or second-line pharmacological therapy for orthostatic hypotension alongside mechanical and positional measures 6
• Midodrine is an effective therapeutic option for the management of various forms of orthostatic hypotension, with similar efficacy to other drugs like dihydroergotamine mesylate and fludrocortisone 7
• Supine hypertension represents a challenge in the treatment of orthostatic hypotension, and elevation of the bed of the head and dosing of short-acting antihypertensive agents at bedtime may be indicated 5

Patient Education and Management

• Education of the patient is an important part of treatment, including educating the patient about the pathophysiology and course of their disorder 5
• Non-pharmacologic therapies and maneuvers are usually effective in relieving symptoms and preventing syncope 5
• Pharmacologic options like fludrocortisones and midodrine are available for patients with severe symptoms 5