How to manage orthostatic (postural) hypotension causing recurrent falls?

Management of Orthostatic Hypotension Causing Recurrent Falls

Treatment of orthostatic hypotension causing recurrent falls 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

Step-by-Step Management Algorithm

Step 1: Non-Pharmacological Interventions (First-Line)

1. 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

2. Compression Garments

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

3. Physical Counterpressure Maneuvers

   • Leg crossing
   • Squatting
   • These can be performed when symptoms begin to appear 1

4. Positional Changes

   • Elevate head of bed 10° when sleeping
   • Avoid sudden position changes
   • These measures reduce nocturnal diuresis and prevent morning orthostatic hypotension 1

5. Dietary Modifications

   • Small, frequent meals
   • Reduce simple carbohydrates
   • Avoid alcohol and hot environments 1

6. Exercise Program

   • Gradual progressive reconditioning
   • Start with recumbent exercises
   • Progress to upright exercises as tolerance improves 1

Step 2: Pharmacological Interventions (If Non-Pharmacological Measures Insufficient)

1. First-Line Medications

   • Fludrocortisone: 0.1mg daily for neurogenic orthostatic hypotension and suspected hypovolemia

     • Monitor for electrolyte imbalances and supine hypertension 1

   • Midodrine: 5-20mg three times daily for symptomatic orthostatic hypotension

     • Last dose should be taken 3-4 hours before bedtime to avoid supine hypertension
     • Can cause marked elevation of supine blood pressure (>200 mmHg systolic)
     • Use only in patients whose lives are considerably impaired despite standard clinical care 1, 2

   • Droxidopa: 100-600mg three times daily for neurogenic orthostatic hypotension

     • Monitor supine blood pressure before and during treatment 1

2. Second-Line Medications

   • Pyridostigmine: 30mg 2-3 times daily for orthostatic hypotension refractory to other treatments
   • Octreotide: For refractory recurrent postprandial or neurogenic orthostatic hypotension
   • Acarbose: For postprandial hypotension, particularly in patients with autonomic dysfunction 1

Special Considerations

Monitoring

• 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 1

Medication Adjustments

• Review and modify medications that may worsen orthostatic hypotension:
  • Antihypertensives
  • Diuretics
  • Antidepressants
  • Alpha-blockers
  • Nitrates 1

Special Populations

• Elderly: Start with lower medication doses due to age-related changes in autonomic function
• Diabetic patients: Focus on glucose control alongside orthostatic management
• Heart failure patients: Use volume-expanding agents cautiously
• Renal impairment: Start with a 2.5 mg dose of midodrine and monitor closely 1, 2

Common Pitfalls to Avoid

1. Focusing on BP numbers rather than symptom improvement

   • Treatment success should be measured by reduction in falls and improved quality of life 1

2. Overlooking non-pharmacological measures

   • Always start with non-pharmacological approaches before medications 1, 3

3. Improper timing of medications

   • Administering vasopressors too close to bedtime can worsen supine hypertension
   • Midodrine should be taken with the last dose 3-4 hours before bedtime 1, 2

4. Inadequate monitoring for supine hypertension

   • This is a serious complication, especially with midodrine
   • Patients should be advised to discontinue medication immediately if supine hypertension persists 1, 2

5. Failure to address underlying causes

   • Always identify and correct reversible causes before starting symptomatic treatment 4

By following this structured approach to managing orthostatic hypotension, you can significantly reduce the risk of recurrent falls and improve quality of life for affected patients.