How to manage orthostatic hypotension?

Management of Orthostatic Hypotension

For patients with orthostatic hypotension, a stepped approach beginning with non-pharmacological measures followed by pharmacological therapy with midodrine as first-line medication is recommended. 1, 2

Definition and Diagnosis

• Orthostatic hypotension (OH) is defined as a decrease in systolic blood pressure ≥20 mmHg or diastolic blood pressure ≥10 mmHg within 3 minutes of standing 3, 4
• Common symptoms include dizziness, lightheadedness, blurred vision, weakness, fatigue, and less commonly syncope, dyspnea, and chest pain 3
• Diagnosis is confirmed by measuring blood pressure after 5 minutes supine and 3 minutes after standing 4

Step 1: Non-Pharmacological Interventions

These should be implemented for all patients with orthostatic hypotension:

1. Fluid and Salt Management:

   • Increase fluid intake to 2-2.5L daily 1
   • Increase salt intake (unless contraindicated by other conditions) 1
   • Acute water ingestion (≥240 mL, with optimal effect at ≥480 mL) can provide temporary relief within 30 minutes 1
   • Note: Pure water is more effective than salt water for immediate pressor response 5

2. Physical Measures:

   • Physical counter-pressure maneuvers (leg crossing, lower body muscle tensing, handgrip) 1
   • Compression garments (thigh-high or abdominal compression) 1
   • Elevate head of bed 10-20 degrees during sleep 6
   • Avoid prolonged standing and rise slowly from lying/sitting positions 6
   • Moderate exercise training to improve vascular tone 1, 6

3. Medication Review:

   • Identify and adjust medications that worsen orthostatic hypotension:
     • Diuretics
     • Vasodilators
     • Alpha-blockers
     • Tricyclic antidepressants 6

Step 2: Pharmacological Therapy

When non-pharmacological measures are insufficient, proceed to medications:

1. First-Line Medication: Midodrine

   • FDA-approved for symptomatic orthostatic hypotension 1, 2
   • Dosing: 10 mg up to 2-4 times daily (last dose at least 3-4 hours before bedtime) 2
   • Mechanism: Alpha-1 agonist causing arterial and venous vasoconstriction 2
   • Increases standing systolic BP by 15-30 mmHg at 1 hour after 10 mg dose 2
   • Caution: Monitor for supine hypertension (BP >200 mmHg systolic) 2

2. Alternative/Additional Options:

   • Fludrocortisone (0.05-0.3 mg daily) 1

     • Acts through sodium retention and vessel wall effects 1
     • Can be used in combination with midodrine for non-responders 1
     • Monitor for supine hypertension, hypokalemia, edema 1

   • Droxidopa 1

     • FDA-approved for neurogenic orthostatic hypotension 1
     • Consider when midodrine and fludrocortisone are ineffective 1
     • May reduce falls in neurogenic OH 1

Special Considerations

1. Neurogenic vs. Non-Neurogenic OH:

   • Neurogenic OH (due to autonomic dysfunction in diabetes, Parkinson's, etc.) may respond better to pharmacological therapy 1
   • Non-neurogenic OH (due to dehydration, medications) often resolves with correction of underlying cause 3

2. Supine Hypertension Management:

   • Common complication of OH treatment 1, 2
   • Strategies to minimize:
     • Take last medication dose 3-4 hours before bedtime 2
     • Sleep with head of bed elevated 2
     • Monitor supine blood pressure regularly 2

3. Treatment Goals:

   • Focus on symptom improvement rather than blood pressure normalization 1, 4
   • Improve standing time and quality of life 4
   • Reduce risk of falls and syncope 3

Monitoring and Follow-up

• Regular blood pressure measurements in supine and standing positions 6
• Assess symptom improvement and medication side effects 2
• Monitor for supine hypertension, especially with pressor medications 1, 2

Common Pitfalls to Avoid

1. Treating asymptomatic orthostatic hypotension unnecessarily 7
2. Focusing solely on BP numbers rather than symptom improvement 1
3. Failing to address underlying reversible causes 3
4. Not considering medication interactions (e.g., cardiac glycosides, beta-blockers) 2
5. Using fludrocortisone as first-line therapy (midodrine has stronger evidence) 1, 4
6. Not monitoring for supine hypertension, which can be severe 2