What is the treatment for orthostatic hypotension?

Treatment of Orthostatic Hypotension

Non-pharmacological approaches are recommended as first-line treatment for orthostatic hypotension, followed by pharmacological therapy with midodrine as the primary medication when symptoms persist despite lifestyle modifications. 1, 2

Definition and Diagnosis

• Orthostatic hypotension is defined as a drop of ≥20 mmHg in systolic BP or ≥10 mmHg in diastolic BP within 3 minutes of standing 1
• Before starting or intensifying BP-lowering medication, testing for orthostatic hypotension is recommended by measuring BP after 5 minutes of sitting/lying and then 1 and/or 3 minutes after standing 2
• Common symptoms include dizziness, lightheadedness, blurred vision, weakness, fatigue, and visual disturbances 1

Treatment Algorithm

Step 1: Non-pharmacological Interventions (First-line)

• Physical counter-pressure maneuvers (leg crossing, squatting, isometric exercises) 1
• Compression garments for lower extremities 1
• Increased salt and fluid intake 1, 3
• Small, frequent meals to reduce postprandial hypotension 1
• Elevating the head of bed during sleep by 6-9 inches (10-20°) to reduce supine hypertension 1
• Avoiding the supine position, which can trigger pressure natriuresis and sodium loss 3

Step 2: Medication Review and Adjustment

• Discontinue or reduce medications that may cause hypotension (e.g., diuretics, alpha-blockers, sedatives) 1
• For patients with hypertension and orthostatic hypotension, switch BP-lowering medications that worsen orthostatic hypotension to alternatives rather than simply reducing dosage 2

Step 3: Pharmacological Therapy (When non-pharmacological measures are insufficient)

First-line medication:

• Midodrine: Alpha-1 adrenergic agonist, 2.5-10 mg three times daily, with last dose at least 4 hours before bedtime 1, 4
  • Monitor for supine hypertension (BP>200 mmHg systolic) 4
  • Contraindicated in patients with severe cardiac disease, acute renal disease, urinary retention, pheochromocytoma, or thyrotoxicosis 4

Alternative/additional medications:

• Fludrocortisone: 0.1-0.3 mg daily, use cautiously due to risk of worsening supine hypertension 1
• Droxidopa: 100-600 mg three times daily, FDA-approved for neurogenic orthostatic hypotension 1
• Pyridostigmine: 30-60 mg three times daily, less likely to cause supine hypertension 1
• Erythropoietin: 25-75 U/kg three times weekly for patients with anemia and severe autonomic dysfunction 1

Special Considerations

Supine Hypertension Management

• Avoid taking medications close to bedtime 4
• Sleep with head of bed elevated 1, 4
• Monitor blood pressure in both supine and standing positions 1

Medication Interactions

• Use caution when combining midodrine with:
  • Other vasoconstrictors (phenylephrine, ephedrine, pseudoephedrine) 4
  • Cardiac glycosides 4
  • Beta-blockers 4
  • MAO inhibitors or linezolid 4

Monitoring and Follow-up

• Regular blood pressure measurements in both supine and standing positions 1
• Follow-up every 3 months once stabilized 1
• Treatment goal is to minimize orthostatic symptoms and improve standing time for activities of daily living, not to normalize blood pressure 1

Cautions and Pitfalls

• Supine hypertension: A common complication of pressor medications, particularly midodrine and fludrocortisone 1, 4
• Renal impairment: Use midodrine cautiously with a starting dose of 2.5 mg as desglymidodrine is eliminated via kidneys 4
• Urinary retention: Monitor patients taking midodrine for urinary retention problems 4
• Bradycardia: Watch for signs of bradycardia with midodrine use, especially when combined with cardiac glycosides 4
• Fludrocortisone: Contraindicated in patients with heart failure and should be used cautiously in patients with supine hypertension 3

By following this structured approach to orthostatic hypotension management, clinicians can effectively improve patients' symptoms and functional capacity while minimizing adverse effects.