How to manage orthostatic hypotension?

Management of Orthostatic Hypotension

The management of orthostatic hypotension should prioritize non-pharmacological measures as first-line treatment, followed by FDA-approved medications such as midodrine and droxidopa for patients with persistent symptoms. 1

Diagnosis and Assessment

Before initiating treatment, proper diagnosis is essential:

• 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
• Measure blood pressure after 5 minutes of lying or sitting, then at 1 and 3 minutes after standing 1
• Document symptoms that correlate with hypotension (dizziness, lightheadedness, fatigue, visual disturbances) 1
• Perform baseline laboratory tests: complete blood count, electrolytes, renal function, blood glucose, and ECG 1

Treatment Algorithm

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

• Physical counter-pressure maneuvers: leg crossing, muscle pumping/contractions, bending forward 1, 2
• Compression garments: abdominal binders and compression stockings 1, 2
• Fluid and salt management:
  • Increase fluid intake (2-3 liters daily)
  • Consume 480 mL of water quickly to raise blood pressure 1, 2
  • Increase salt intake (unless contraindicated) 1
• Dietary modifications:
  • Small, frequent meals to reduce postprandial hypotension 1
  • Limit alcohol consumption 1
• Sleep adjustments: Elevate head of bed 6-9 inches during sleep 1
• Physical activity: Regular exercise to prevent deconditioning 3, 1

Step 2: Pharmacological Treatment (For Persistent Symptoms)

First-line medications:

• Midodrine (10 mg up to 2-4 times daily): Alpha-1 agonist, FDA-approved 1, 4

  • Last dose should be taken 3-4 hours before bedtime to avoid supine hypertension 4
  • Monitor for supine hypertension, urinary retention, and bradycardia 4

• Droxidopa (100-600 mg three times daily): FDA-approved specifically for neurogenic orthostatic hypotension 3, 1

  • Last dose at least 4 hours before bedtime 1

Second-line medications:

• Fludrocortisone (0.05-0.1 mg daily, titrated to 0.1-0.3 mg daily): Promotes sodium retention 1, 5

  • Monitor for supine hypertension, edema, and hypokalemia

• Pyridostigmine: For patients with less severe symptoms 5

• Acarbose or octreotide: For severe postprandial hypotension 5

Special Considerations

Managing Supine Hypertension

• Use shorter-acting antihypertensives at bedtime: 3, 1
  • Guanfacine or clonidine
  • Short-acting calcium blockers (e.g., isradipine)
  • Short-acting β-blockers (e.g., atenolol, metoprolol tartrate)
  • Enalapril (if unable to tolerate preferred agents)

Medication Review

• Avoid or minimize medications that worsen orthostatic hypotension: 1
  • Opioids
  • Anticholinergics
  • Tricyclic antidepressants
  • Vasodilators
  • Diuretics

Monitoring and Follow-up

• Regular blood pressure measurements in supine and standing positions 1
• Target symptom improvement rather than normalization of blood pressure 3, 1
• Follow-up every 3 months once stabilized 1
• Consider specialist referral for refractory cases 1

Pitfalls and Caveats

• Avoid excessive supine hypertension: Monitor BP in both positions, especially when using pressor medications 4
• Medication timing is critical: Administer last dose of midodrine or droxidopa several hours before bedtime 1, 4
• Be cautious with concomitant medications: Midodrine may interact with cardiac glycosides, beta-blockers, and other vasoconstrictors 4
• Renal impairment: Use midodrine cautiously with reduced starting dose (2.5 mg) in patients with kidney disease 4
• Treatment goals: Focus on minimizing symptoms rather than normalizing blood pressure values 3, 1

By following this structured approach to orthostatic hypotension management, clinicians can effectively improve patients' quality of life while minimizing adverse effects.