What are the treatment options for orthostatic hypotension?

Treatment Options for Orthostatic Hypotension

Non-pharmacological approaches should be the first-line treatment for orthostatic hypotension, followed by pharmacological options only when symptoms persist despite these measures. 1

Non-Pharmacological Management

First-Line Measures

• Fluid and Salt Intake

  • Increase fluid intake to 2-3 liters daily
  • Increase salt intake to 6-9g daily (especially important in patients with supine hypertension) 1

• Compression Garments

  • Thigh-high stockings with 30-40 mmHg pressure
  • Abdominal binders 1

• Physical Counterpressure Maneuvers

  • Leg crossing
  • Squatting
  • These techniques help increase venous return 1

Positional and Lifestyle Modifications

• Elevate head of bed by 10° when sleeping to reduce nocturnal diuresis
• Avoid sudden position changes (rise slowly from lying to sitting, then to standing)
• Consume small, frequent meals with reduced simple carbohydrates
• Avoid alcohol and hot environments
• Maintain a cool environment 1

Exercise Program

• Implement structured, gradual progressive reconditioning
• Start with recumbent exercises
• Progress to upright exercises as tolerance improves 1

Pharmacological Management

First-Line Medications

1. Fludrocortisone

   • Dosing: 0.1mg daily
   • Indications: Neurogenic orthostatic hypotension and suspected hypovolemia
   • Monitoring: Electrolyte imbalances and supine hypertension 1

2. Midodrine

   • Dosing: 5-20mg three times daily (last dose no later than 6 PM)
   • Indications: Symptomatic orthostatic hypotension refractory to non-pharmacological measures
   • Effects: Increases standing systolic BP by 15-30 mmHg for 2-3 hours
   • Caution: Can cause marked elevation of supine BP (>200 mmHg systolic)
   • Monitoring: Supine hypertension 1, 2

3. Droxidopa

   • Dosing: 100-600mg three times daily
   • Indications: Symptomatic neurogenic orthostatic hypotension
   • Monitoring: Supine blood pressure before and during treatment 1

Second-Line Medications

• Pyridostigmine: 30mg 2-3 times daily for OH refractory to other treatments
• Octreotide: For refractory recurrent postprandial or neurogenic OH
• Acarbose: For postprandial hypotension, particularly in patients with autonomic dysfunction
• Beta-blockers (e.g., metoprolol, nebivolol, bisoprolol): For resting tachycardia in patients with dysautonomia 1

Special Populations

Elderly Patients

• More vulnerable due to age-related changes in autonomic function
• Start with lower medication doses 1

Patients with Renal Impairment

• Start with 2.5 mg dose of midodrine
• Monitor closely as desglymidodrine is eliminated via kidneys 1, 2

Heart Failure Patients

• Use volume-expanding agents cautiously 1

Monitoring and Follow-up

• Measure blood pressure in both supine and standing positions
• Monitor for supine hypertension (particularly with midodrine)
• Track symptom improvement with a diary
• Regular weight assessment and electrolyte monitoring (particularly with fludrocortisone)
• Heart rate monitoring during position changes 1, 2

Common Pitfalls to Avoid

1. Focusing on BP numbers rather than symptom improvement 1
2. Overlooking non-pharmacological measures before starting medications 1
3. Improper timing of medications (e.g., administering vasopressors too close to bedtime) 1, 2
4. Inadequate monitoring for supine hypertension 1, 2
5. Failure to discontinue or adjust medications that worsen orthostatic hypotension 1
6. Continuing midodrine in patients who don't report significant symptomatic improvement 2

Drug Interactions

• Use caution when combining midodrine with:
  • Cardiac glycosides (may enhance bradycardia)
  • Other vasoconstrictors (phenylephrine, ephedrine, etc.)
  • MAO inhibitors or linezolid
  • Alpha-adrenergic blocking agents (can antagonize midodrine effects) 2