How to manage orthostatic hypotension?

Management of Orthostatic Hypotension

The first-line treatment for orthostatic hypotension should be non-pharmacological approaches, including physical counter-pressure maneuvers, compression garments, increased salt and fluid intake, small frequent meals, and elevating the head of bed during sleep. 1

Definition and Diagnosis

Orthostatic hypotension is defined as:

• Decrease in systolic blood pressure ≥20 mmHg or diastolic ≥10 mmHg within 3 minutes of standing from a seated or supine position 1, 2, 3
• Diagnosis requires measuring blood pressure after 5 minutes of lying/sitting, then at 1 and 3 minutes after standing 1
• Common symptoms include dizziness, lightheadedness, blurred vision, weakness, fatigue, and less commonly syncope and coat hanger pain (neck/shoulder pain) 1, 3

Treatment Algorithm

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

• Physical counter-pressure maneuvers (leg crossing, squatting)
• Compression garments (waist-high stockings)
• Increased salt and fluid intake (note: water alone can increase systolic BP by >30 mmHg in many patients) 1, 4
• Small, frequent meals to avoid postprandial hypotension
• Elevating the head of bed during sleep (10-20°)
• Regular exercise to prevent deconditioning 1

Important note: Interestingly, drinking plain water (480 mL) can provide a significant acute pressor response and may be more effective than salt water for immediate BP elevation 5, 4. Water drinking can increase standing BP from 83/53 mmHg to 114/66 mmHg within 35 minutes 4.

Step 2: Medication Review and Adjustment

• Identify and discontinue medications that worsen orthostatic hypotension 1, 6:
  • Antihypertensives (especially alpha-1 blockers, centrally acting agents)
  • Psychiatric medications (phenothiazines, tricyclic antidepressants, MAOIs)
  • Opioids
  • Anticholinergics
  • Diuretics (if causing volume depletion)

Step 3: Pharmacological Treatment

If symptoms persist despite non-pharmacological measures:

1. Midodrine (10 mg up to 2-4 times daily) 1, 7

   • Alpha-1 agonist
   • FDA-approved for symptomatic orthostatic hypotension
   • Last dose should be at least 3-4 hours before bedtime to minimize supine hypertension
   • Can increase standing systolic BP by 15-30 mmHg within 1 hour 7
   • Caution: Monitor for supine hypertension (BP >200 mmHg systolic) 7

2. Fludrocortisone (0.05-0.1 mg daily, titrated to 0.1-0.3 mg daily) 1

   • Promotes sodium retention and vessel wall constriction
   • Use with caution in patients with heart failure or renal impairment

3. Droxidopa (100-600 mg three times daily) 1, 3

   • FDA-approved for neurogenic orthostatic hypotension
   • Last dose at least 4 hours before bedtime

Monitoring and Follow-up

• Regular BP measurements in supine and standing positions to assess treatment effectiveness 1
• Monitor for supine hypertension, especially with pressor medications 1, 7
• Follow-up every 3 months once stabilized 1
• For patients on midodrine, assess for symptomatic improvement and continue only if significant benefit is reported 7

Special Considerations

• Target BP goal: Minimize postural symptoms rather than restore normotension 1
• Supine hypertension management: Prevent full supine position by elevating head of bed; last dose of pressor medications should be several hours before bedtime 1, 7
• Renal impairment: Use midodrine with caution, starting at lower doses (2.5 mg) 7
• Urinary retention: Use midodrine cautiously in patients with urinary problems as it acts on alpha-adrenergic receptors of the bladder neck 7
• Drug interactions: Avoid concomitant use of midodrine with other vasoconstrictors, MAO inhibitors, or cardiac glycosides 7

When to Refer to a Specialist

Referral is necessary for:

• Refractory hypotension despite initial management
• Suspected secondary causes
• Hypotension with multiple cardiovascular risk factors 1