What are the next steps for managing persistent orthostatic hypotension despite initial treatment with increased fluid intake and compression stockings?

From the Guidelines

Next steps for managing persistent orthostatic hypotension despite initial treatment with increased fluid intake and compression stockings are to consider pharmacologic measures such as midodrine, droxidopa, or fludrocortisone, as these have been shown to be beneficial in patients with neurogenic orthostatic hypotension 1.

Non-Pharmacologic Interventions

• Physical counter-pressure maneuvers such as leg crossing, lower body muscle tensing, and maximal force handgrip can increase blood pressure 1
• Compression garments that are at least thigh high and preferably include the abdomen can improve orthostatic symptoms and blunt associated decreases in blood pressure 1
• Increased salt and fluid intake may be reasonable in selected patients with neurogenic OH, although the long-term effects of these treatments are unknown 1

Pharmacologic Interventions

• Midodrine is a first-line drug that exerts a pressor effect through both arteriolar constriction and venoconstriction of the capacitance vessels, with a dosing regimen of up to two to four times 10 mg/day 1
• Droxidopa improves symptoms of neurogenic OH due to Parkinson disease, pure autonomic failure, and multiple system atrophy, although its use may be limited by supine hypertension and other side effects 1
• Fludrocortisone increases plasma volume, with a resultant improvement in symptoms of OH, although supine hypertension may be a limiting factor 1
• Other possible treatments include pyridostigmine, octreotide, and erythropoietin, although these may be considered second-line or in specific cases 1

From the Research

Next Steps for Managing Persistent Orthostatic Hypotension

The next steps for managing persistent orthostatic hypotension despite initial treatment with increased fluid intake and compression stockings include:

• Reviewing medications and modifying or removing those that may aggravate or cause orthostatic hypotension 2
• Implementing pharmacologic measures, such as volume repletion in combination with alpha-adrenoreceptor agonists 3
• Using supplementary agents with different mechanisms of action to provide an additive effect 3
• Considering the use of fludrocortisone and midodrine, which are commonly used to treat orthostatic hypotension 4
• Applying abdominal binders to improve venous return, as splanchnic venous pooling is often overlooked 5
• Avoiding bedrest deconditioning and using pressors as part of an orthostatic rehab program to reduce hospital stay 5
• Selecting pharmacologic treatments based on the patient's underlying pathophysiology and residual sympathetic tone, such as "norepinephrine enhancers" or "replacers" 6

Pharmacologic Treatment Options

Pharmacologic treatment options for orthostatic hypotension include:

• Midodrine, a peripheral, selective alpha1-adrenergic agonist that causes arterial and venous vasoconstriction 4
• Fludrocortisone, which expands the extravascular body fluid volume and improves alpha-adrenergic sensitivity 4
• Pyridostigmine, atomoxetine, and yohimbine, which are "norepinephrine enhancers" that can be effective in patients with relatively preserved sympathetic reserve 6
• Droxidopa, which is a "norepinephrine replacer" that can be effective in patients with low sympathetic reserve 6