What is the treatment for orthostatic hypotension?

Treatment of Orthostatic Hypotension

The treatment of orthostatic hypotension should follow a sequential approach: first reviewing and modifying medications that may cause or worsen OH, then implementing non-pharmacological measures, followed by pharmacological therapy, and finally considering combination treatments when necessary. 1

Initial Assessment and Non-Pharmacological Management

Step 1: Medication Review

• Identify and modify/discontinue medications that may cause or worsen orthostatic hypotension 1, 2
• Common culprits include antihypertensives, diuretics, antidepressants, and alpha-blockers

Step 2: Non-Pharmacological Measures

These should be offered to all patients before starting medications 1, 3:

• Volume expansion:

  • Increase salt intake to target 10g of NaCl daily 1
  • Increase fluid intake to 2-3L per day 1
  • Avoid alcohol and hot environments 1

• Reduce venous pooling:

  • Wear waist-high or at minimum thigh-high compression stockings (30-40 mmHg pressure) 1
  • Use physical counterpressure maneuvers (leg crossing, squatting, muscle tensing) 1

• Positional modifications:

  • Elevate head of bed by 10° to prevent nocturnal polyuria 1
  • Avoid sudden position changes 1
  • Sleep in semi-recumbent position 3

• Dietary modifications:

  • Eat small, frequent meals with reduced simple carbohydrates 1
  • Increase protein and fiber intake 1
  • Separate liquids from solids by at least 30 minutes 1

Pharmacological Management

When non-pharmacological measures are insufficient, medications should be considered:

First-Line Medications:

1. Midodrine:

   • Starting dose: 5mg three times daily 1
   • Maximum dose: 10-20mg three times daily 1
   • Last dose at least 4 hours before bedtime to prevent supine hypertension 1
   • FDA-approved for symptomatic orthostatic hypotension in patients whose lives are considerably impaired despite standard clinical care 4
   • Dose adjustment: Start with 2.5mg in renal impairment 1

2. Fludrocortisone:

   • Dosing: 0.1mg daily 1
   • Mechanism: Volume expansion and increased sensitivity to norepinephrine
   • Monitoring: Regular electrolyte and weight assessment 1

Second-Line Medications:

1. Droxidopa:

   • Dosing: 100-600mg three times daily 1
   • Particularly beneficial for neurogenic orthostatic hypotension 1

2. Pyridostigmine:

   • Dosing: 30mg 2-3 times daily 1
   • Useful for orthostatic hypotension refractory to other treatments 1
   • May improve OH without worsening supine hypertension 5

3. Other options for specific scenarios:

   • Octreotide: For refractory recurrent postprandial or neurogenic OH 1
   • Acarbose: For postprandial hypotension, particularly with autonomic dysfunction 1
   • Beta-blockers: For resting tachycardia in patients with dysautonomia 1

Special Populations

• Diabetic patients: Focus on glucose control alongside OH management 1
• Heart failure patients: Use volume-expanding agents cautiously 1
• Elderly patients: Start with lower medication doses 1, 6
• Pregnant patients: Prioritize volume expansion with IV fluids for acute management 1

Monitoring and Follow-up

• Monitor for supine hypertension by measuring BP in both supine and standing positions 1
• Regular weight assessment and electrolyte monitoring, particularly with fludrocortisone 1
• Track symptom improvement using a diary 1
• Continue medications only for patients who report significant symptomatic improvement 4

Common Pitfalls to Avoid

• Failing to test for orthostatic hypotension before starting or intensifying BP-lowering medication 1
• Overlooking orthostatic hypotension as a cause of falls in elderly patients 1
• Focusing on BP numbers rather than symptom improvement 1
• Administering vasopressors too close to bedtime, which can worsen supine hypertension 1
• Inadequate monitoring for supine hypertension 1
• Starting with pharmacological therapy before optimizing non-pharmacological measures 1, 3

Remember that the goal of treatment is to improve symptoms and quality of life, not necessarily to normalize blood pressure readings 6. Treatment success should be measured by reduction in falls, increased standing time, and improved ability to perform daily activities 3.