What are the treatment options for orthostatic hypotension?

Treatment Options for Orthostatic Hypotension

Treatment of orthostatic hypotension should begin with non-pharmacological approaches including increased fluid intake, compression garments, and physical counterpressure maneuvers before considering pharmacological treatments such as fludrocortisone, midodrine, or droxidopa. 1

Non-Pharmacological Management (First-Line)

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

Physical Countermeasures

• Compression garments: thigh-high stockings with 30-40 mmHg pressure
• Abdominal binders
• Physical counterpressure maneuvers (leg crossing, squatting) 1

Positional Modifications

• Elevate head of bed 10° when sleeping
• Avoid sudden position changes
• Sleep with head elevated to prevent supine hypertension 1

Lifestyle Adjustments

• Consume small, frequent meals with reduced simple carbohydrates
• Avoid alcohol and hot environments
• Implement a structured exercise program, starting with recumbent exercises and progressing to upright exercises 1

Pharmacological Management (Second-Line)

First-Line Medications

1. Fludrocortisone

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

2. Midodrine

   • Dosage: 5-20mg three times daily (start with 2.5mg in renal impairment)
   • Indication: Symptomatic orthostatic hypotension refractory to non-pharmacological measures
   • Timing: Last dose should be taken 3-4 hours before bedtime to minimize nighttime supine hypertension
   • Caution: Can cause marked elevation of supine blood pressure (>200 mmHg systolic) 1, 2

3. Droxidopa

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

Second-Line Medications

1. Pyridostigmine

   • Dosage: 30mg 2-3 times daily
   • Indication: Orthostatic hypotension refractory to other treatments 1

2. Octreotide

   • Indication: Refractory recurrent postprandial or neurogenic orthostatic hypotension 1

3. Acarbose

   • Indication: Postprandial hypotension, particularly in patients with autonomic dysfunction 1

Special Populations Considerations

Elderly Patients

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

Patients with Renal Impairment

• Start with 2.5mg dose of midodrine
• Monitor closely
• Assess renal function prior to initiating therapy 1, 2

Patients with Cardiac Conditions

• Use caution with midodrine in patients taking cardiac glycosides
• Monitor for bradycardia, A-V block, or arrhythmia 2

Monitoring and Follow-up

1. Blood Pressure Monitoring

   • Measure BP in both supine and standing positions
   • Monitor for supine hypertension (particularly with midodrine) 1, 2

2. Weight and Electrolyte Assessment

   • Regular weight assessment
   • Electrolyte monitoring (particularly with fludrocortisone) 1

3. Symptom Tracking

   • Use a symptom diary to track frequency and severity of symptoms 1

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. Continuing midodrine in patients who don't report significant symptomatic improvement 2
6. Using midodrine concomitantly with other vasoconstrictors (phenylephrine, ephedrine, dihydroergotamine) without careful BP monitoring 2

Drug Interactions to Monitor

• Cardiac glycosides may enhance bradycardia when used with midodrine
• MAO inhibitors or linezolid should be avoided with midodrine
• Alpha-adrenergic blocking agents can antagonize the effects of midodrine 2

Remember that treatment should focus on improving symptoms and quality of life rather than normalizing orthostatic blood pressure measurements alone 3.