What is the treatment for orthostatic hypotension?

Treatment of Orthostatic Hypotension

The treatment of orthostatic hypotension should begin with non-pharmacological approaches as first-line therapy, followed by medications such as midodrine or droxidopa only when symptoms persist despite conservative measures. 1

Initial Assessment and Management

1. Review and modify medications that may cause or worsen orthostatic hypotension:

   • Opioids
   • Anticholinergics
   • Tricyclic antidepressants 1

2. Non-pharmacological interventions (first-line treatment):

   • Physical counter-pressure maneuvers
   • Compression garments for lower extremities
   • Increased salt and fluid intake (unless contraindicated)
   • Small, frequent meals to reduce post-prandial hypotension
   • Elevating the head of bed during sleep (10-20 degrees)
   • Regular exercise to prevent deconditioning 1, 2

Pharmacological Treatment

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

1. Midodrine:

   • Dosage: 10 mg up to 2-4 times daily
   • Mechanism: Alpha-1 agonist
   • Indication: For symptomatic orthostatic hypotension in patients whose lives are considerably impaired despite standard clinical care
   • Caution: Can cause marked elevation of supine blood pressure (>200 mmHg systolic)
   • Monitoring: Should be continued only for patients who report significant symptomatic improvement 1, 3

2. Fludrocortisone:

   • Dosage: 0.05-0.1 mg daily, titrated to 0.1-0.3 mg daily
   • Mechanism: Sodium retention, vessel wall constriction, and reduced vessel distensibility 1

3. Droxidopa:

   • Dosage: 100-600 mg three times daily (last dose at least 4 hours before bedtime)
   • Indication: FDA-approved specifically for neurogenic orthostatic hypotension
   • Monitoring: Effectiveness beyond 2 weeks of treatment has not been established and should be assessed periodically 1, 4

4. Erythropoietin:

   • Dosage: 25-75 U/kg three times weekly
   • Indication: For patients with anemia and severe autonomic dysfunction 1

Treatment Goals and Monitoring

• The therapeutic goal is to minimize postural symptoms rather than restore normotension 1

• Target BP goals:

  • <130/80 mmHg for most adults
  • <130 mmHg for ambulatory community-dwelling older adults (≥65 years) 1

• Regular monitoring:

  • Measure blood pressure in both supine and standing positions
  • Watch for supine hypertension, especially with pressor medications
  • Follow up every 3 months once stabilized 1

Special Considerations

• Supine hypertension: A common complication of treatment, particularly with midodrine. Schedule last dose at least 4 hours before bedtime 1, 3
• Post-prandial hypotension: Small, frequent meals can help minimize this effect 1
• Environmental factors: Avoid hot environments and prolonged standing, which can exacerbate symptoms 2

Referral Criteria

Consider specialist referral for:

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

Patient Education

• Teach patients to recognize prodromal symptoms to help identify impending episodes
• Educate on physical counter-maneuvers (crossing legs, squatting) to use when symptoms occur
• Emphasize the importance of gradual position changes, especially when rising from bed 1

The treatment approach should be stepped, starting with non-pharmacological measures and adding medications only when necessary, with the primary goal of improving functional capacity and quality of life rather than achieving specific blood pressure targets.