Treatment of Orthostatic Hypotension
The first-line treatment for orthostatic hypotension should include non-pharmacological measures, with midodrine as the primary pharmacological intervention for symptomatic cases that don't respond to conservative management. 1, 2
Definition and Diagnosis
- Orthostatic hypotension is defined as a decrease in systolic blood pressure ≥20 mmHg or diastolic blood pressure ≥10 mmHg within 3 minutes of standing 3
- Common symptoms include dizziness, lightheadedness, blurred vision, weakness, fatigue, and less commonly syncope, dyspnea, and neck/shoulder pain 4
Treatment Algorithm
Step 1: Non-pharmacological Interventions (First-line)
- Increase fluid intake to 2-2.5L daily and moderate salt intake (unless contraindicated) 5
- Physical countermeasures:
- Rise slowly from lying or sitting positions
- Avoid prolonged standing
- Elevate head of bed during sleep (10-20 degrees)
- Use compression garments/stockings for lower extremities
- Perform isometric counterpressure exercises (leg crossing, muscle tensing)
- Maintain moderate physical activity to improve vascular tone 1, 5
- Identify and discontinue medications that exacerbate orthostatic hypotension:
- Antihypertensives
- Diuretics
- Alpha-blockers
- Vasodilators
- Tricyclic antidepressants 5
Step 2: Pharmacological Interventions (For symptomatic cases not responding to non-pharmacological measures)
First-line Medications:
- Midodrine (FDA-approved for symptomatic orthostatic hypotension)
Second-line Medications:
Fludrocortisone (9-α-fluorohydrocortisone)
- Dosing: Initial dose 0.05-0.1 mg daily, titrate to 0.1-0.3 mg daily
- Mechanism: Sodium retention, vessel wall constriction, reduced vessel distensibility
- Can be used in combination with midodrine for severe cases
- Caution: Monitor for supine hypertension, hypokalemia, congestive heart failure, peripheral edema 1
Droxidopa (FDA-approved for neurogenic orthostatic hypotension)
Additional Pharmacological Options:
- For patients with morning orthostatic hypotension: administer medications in the evening 5
- For patients on antihypertensives: consider bedtime administration 5
- For patients with supine hypertension: use shorter-acting drugs at bedtime:
- Guanfacine or clonidine
- Shorter-acting calcium blockers (e.g., isradipine)
- Shorter-acting β-blockers (atenolol, metoprolol tartrate)
- Alternative: enalapril if unable to tolerate preferred agents 1
Special Considerations
Treatment Goals
- Focus on symptom improvement rather than blood pressure normalization 1
- Improve standing time and ability to perform daily activities 2
- Balance treatment of orthostatic hypotension with management of supine hypertension 6
Monitoring
- Regular blood pressure measurements in supine and standing positions to assess treatment effectiveness 5
- Monitor for supine hypertension, especially with pressor medications 5
- Continue treatment only for patients who report significant symptomatic improvement 2
Pitfalls and Caveats
- Avoid excessive supine hypertension when treating orthostatic hypotension 2
- Be cautious with fludrocortisone in patients with heart failure or supine hypertension 6
- Midodrine can cause marked elevation of supine blood pressure (>200 mmHg systolic) 2
- Avoid the supine position in patients with supine hypertension, as this triggers pressure natriuresis and sodium loss 6
- The use of any opioids for management of symptoms should be avoided due to addiction risk 1
By following this algorithm and considering both non-pharmacological and pharmacological interventions, most patients with orthostatic hypotension can achieve significant symptom improvement and better quality of life.