What is the initial management approach for patients with neurogenic orthostatic hypotension (OH) and random hypotension?

Initial Management of Neurogenic Orthostatic Hypotension with Random Hypotension

Non-pharmacological approaches should be the first-line treatment for patients with neurogenic orthostatic hypotension (nOH) and random hypotension, including increased fluid intake (2-3 liters daily), increased salt intake (6-9g daily), compression garments, and physical counterpressure maneuvers. 1

Diagnosis and Assessment

Before initiating treatment, it's important to:

• Confirm orthostatic hypotension: ≥20 mmHg drop in systolic or ≥10 mmHg drop in diastolic BP within 3 minutes of standing 1
• Measure BP in both supine and standing positions to assess for supine hypertension
• Identify medications that may cause or worsen orthostatic hypotension:
  • Antihypertensives
  • Diuretics
  • Antidepressants
  • Antipsychotics
  • Antiparkinsonian medications
  • Opioids 1

Initial Management Algorithm

Step 1: Non-pharmacological Approaches

• Increase fluid intake to 2-3 liters daily 1
• Increase salt intake to 6-9g daily 1
• Use compression garments (thigh-high stockings with 30-40 mmHg pressure) 1
• Apply abdominal binders 1
• Employ physical counterpressure maneuvers (leg crossing, squatting) 1
• Implement positional changes:
  • Elevate head of bed 10° when sleeping
  • Avoid sudden position changes 1
• Modify daily habits:
  • Consume small, frequent meals with reduced simple carbohydrates
  • Avoid alcohol and hot environments
  • Maintain a cool environment 1

Step 2: Dietary Modifications for Postprandial Hypotension

• Avoid refined carbohydrates
• Increase protein and fiber intake
• Separate liquids from solids by at least 30 minutes 1

Step 3: Pharmacological Approaches (if non-pharmacological measures are insufficient)

For neurogenic orthostatic hypotension specifically:

1. Fludrocortisone: 0.1mg daily 1
2. Droxidopa: 100-600mg three times daily 1, 2
   • FDA-approved specifically for symptomatic nOH caused by primary autonomic failure
   • Note: Effectiveness beyond 2 weeks is uncertain; patients should be evaluated periodically 2
3. Midodrine: 5-20mg three times daily (for symptomatic OH refractory to non-pharmacological measures) 1
4. Pyridostigmine: 30mg 2-3 times daily (for OH refractory to other treatments) 1

Special Considerations

Supine Hypertension

• Monitor for supine hypertension, a common side effect of pressor agents 1
• Droxidopa causes elevations in blood pressure and increases the risk of supine hypertension 2
• Implement strategies to minimize supine hypertension:
  • Head-of-bed elevation
  • Avoid taking medications before bedtime 1

Monitoring

• Regular weight assessment and electrolyte monitoring, particularly with fludrocortisone 1
• Assess continued effectiveness of treatment periodically, especially with droxidopa 2
• Monitor heart rate during position changes to assess improvement 1
• Consider using a symptom diary to track frequency and severity of symptoms 1

Common Pitfalls to Avoid

• Failing to test for orthostatic hypotension before starting or intensifying blood pressure-lowering medication 1
• Overlooking non-pharmacological measures before starting medications 1
• Improper timing of medications (e.g., administering vasopressors too close to bedtime) 1
• Inadequate monitoring for supine hypertension 1
• Focusing on BP numbers rather than symptom improvement 1
• Failure to switch BP-lowering medications that worsen orthostatic hypotension to alternative therapies 1