What is the initial management for a patient with orthostatic hypotension?

Management of Orthostatic Hypotension

The initial management for orthostatic hypotension should focus on non-pharmacological interventions including increased fluid intake (2-2.5L daily), moderate salt intake, and physical countermeasures before considering pharmacological therapy. 1

Definition and Diagnosis

Orthostatic hypotension is defined as:

• Decrease in systolic blood pressure ≥20 mmHg or diastolic blood pressure ≥10 mmHg within 3 minutes of standing 1

Step-by-Step Management Approach

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

• Fluid and Salt Intake:

  • Increase fluid intake to 2-2.5L daily 1
  • Moderate salt intake (unless contraindicated) 1
  • Consider "sport" drinks with electrolytes 2

• Physical Countermeasures:

  • Rise slowly from lying or sitting positions 1
  • Avoid prolonged standing 1
  • Elevate head of bed during sleep (to reduce nocturnal diuresis) 1
  • Use compression garments/stockings for lower extremities 1
  • Perform isometric counterpressure exercises (leg crossing, muscle tensing) 1
  • Maintain moderate physical activity to improve vascular tone 1
  • Consider "tilt-training" for highly motivated patients with recurrent symptoms 2

Step 2: Medication Review and Adjustment

• Identify and adjust medications that may worsen orthostatic hypotension 1:
  • Antihypertensives
  • Diuretics
  • Alpha-blockers
  • Vasodilators
  • Tricyclic antidepressants

Step 3: Pharmacological Interventions (When Non-Pharmacological Measures Are Insufficient)

1. First-Line Medication:

   • Midodrine (alpha-1 agonist): 10 mg up to 2-4 times daily 1, 3
     • Increases standing systolic BP by 15-30 mmHg at 1 hour after a 10 mg dose 3
     • Last dose should not be taken later than 6 PM to avoid supine hypertension 3
     • Continue only in patients reporting significant symptomatic improvement 3

2. Alternative/Additional Options:

   • Fludrocortisone: Initial dose 0.05-0.1 mg daily, titrated to 0.1-0.3 mg daily 1
     • Can be used in combination with midodrine for severe cases 1
   • Droxidopa: Consider when midodrine and fludrocortisone are ineffective 1

Special Considerations

Monitoring

• Regular blood pressure measurements in both supine and standing positions 1
• Monitor for supine hypertension, especially with pressor medications 1, 3
• Evaluate treatment effectiveness based on symptom improvement rather than BP normalization 1

Supine Hypertension Management

• Avoid taking pressor medications before bedtime 1
• Consider short-acting antihypertensives at bedtime if severe supine hypertension develops 1

Cautions

• Midodrine can cause marked elevation of supine blood pressure (>200 mmHg systolic) 3
• Supine systolic pressure was ≥200 mmHg in 22% of patients on 10 mg midodrine 3
• Avoid midodrine in patients with pre-existing sustained supine hypertension above 180/110 mmHg 3

Specific Patient Populations

• Elderly patients: Systematically search for orthostatic hypotension before initiating or intensifying antihypertensive treatment 1
• Patients with heart failure: Continue SGLT2 inhibitors and MRAs; consider reducing doses of ACEi/ARB/ARNI and beta-blockers 1
• Patients with diabetes: Be aware that diabetic autonomic neuropathy commonly causes orthostatic hypotension 1
• Patients on hemodialysis: Note that midodrine is removed by dialysis 3

Remember that the goal of treatment is improving functional capacity and quality of life rather than achieving specific blood pressure targets 1, 4.