What are the management options for orthostatic hypotension?

Management of Orthostatic Hypotension

Non-pharmacological measures should be the first-line approach for managing orthostatic hypotension, followed by pharmacological therapy with midodrine or fludrocortisone for patients with persistent symptomatic orthostatic hypotension. 1, 2

Step 1: Identify and Address Underlying Causes

• Review and modify medications that may cause or worsen orthostatic hypotension:
  • Antihypertensives
  • Diuretics
  • Alpha-blockers
  • Vasodilators
  • Tricyclic antidepressants 1
• Assess for underlying conditions:
  • Diabetes
  • Parkinson's disease
  • Autonomic neuropathy 1

Step 2: Non-Pharmacological Interventions

Immediate Measures

• Physical counter-pressure maneuvers:
  • Leg crossing
  • Squatting
  • Isometric exercises 1
• Compression garments:
  • Thigh-high stockings
  • Abdominal compression 1, 3

Lifestyle Modifications

• Elevate head of bed by 6-9 inches (10-20°) during sleep 1
• Increase salt and fluid intake (2-2.5 L/day) if not contraindicated 1
• Consume small, frequent meals to reduce postprandial hypotension 1, 3
• Gradual staged movements with postural change 1
• Avoid alcohol and hot environments 3

Step 3: Pharmacological Management

First-Line Medications

• Midodrine:

  • Dosage: 2.5-10 mg three times daily
  • Last dose at least 4 hours before bedtime
  • FDA-approved for symptomatic orthostatic hypotension
  • Monitor for supine hypertension (BP>200 mmHg systolic) 1, 4

• Fludrocortisone:

  • Dosage: 0.1-0.3 mg daily
  • Mechanism: Sodium retention, vessel wall constriction
  • Use cautiously due to risk of worsening supine hypertension 1, 2

Alternative Medications

• Droxidopa:

  • Dosage: 100-600 mg three times daily
  • Last dose at least 4 hours before bedtime
  • FDA-approved for neurogenic orthostatic hypotension 1, 5

• Pyridostigmine:

  • Dosage: 30-60 mg three times daily
  • Less likely to cause supine hypertension
  • Better option for heart failure patients 1, 5

• Other options for specific cases:

  • Somatostatin analogues (for postprandial hypotension)
  • Caffeine
  • Acarbose (for postprandial hypotension) 2, 5

Special Considerations

Supine Hypertension Management

• Avoid taking pressor medications within 4 hours of bedtime 1, 4
• Elevate head of bed during sleep 1
• Monitor blood pressure in both supine and standing positions 1

Heart Failure Patients

• Pyridostigmine preferred as it's less likely to cause supine hypertension
• Midodrine, droxidopa, salt tablets, and fludrocortisone may be poorly tolerated 1

Treatment Goals and Monitoring

• Focus on minimizing orthostatic symptoms and improving standing time for activities of daily living, not normalizing blood pressure 1
• Regular blood pressure measurements in supine and standing positions to assess treatment effectiveness and monitor for supine hypertension 1
• Continue treatment only for patients who report significant symptomatic improvement 4

Common Pitfalls to Avoid

• Failing to recognize supine hypertension, which can lead to target organ damage 1
• Using pressor medications too close to bedtime 1, 4
• Rapidly lowering blood pressure in asymptomatic patients 1
• Focusing solely on normalizing blood pressure rather than symptom improvement 1
• Not monitoring renal function when using midodrine in patients with renal impairment 4

By following this stepwise approach, most patients with orthostatic hypotension can achieve significant symptom improvement and better quality of life.