What is the treatment for orthostatic hypotension?

Treatment of Orthostatic Hypotension

The first-line treatment for orthostatic hypotension should include non-pharmacological interventions such as acute water ingestion, physical counter-pressure maneuvers, compression garments, and increased salt and fluid intake, followed by pharmacological options like midodrine, droxidopa, or fludrocortisone for patients with persistent symptoms. 1

Definition and Diagnosis

Orthostatic hypotension is defined as a 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:

• Blood pressure measurements after 5 minutes lying/sitting, then at 1 and 3 minutes after standing
• Documentation of associated symptoms: dizziness, lightheadedness, fatigue, visual disturbances
• Evaluation of electrolytes, renal function, and tests for autonomic cardiovascular neuropathy

Treatment Algorithm

Step 1: Non-Pharmacological Interventions

These should be tried first in all patients:

• Acute water ingestion (Class I recommendation): 16 oz (480 mL) of water for temporary relief 1
• Physical counter-pressure maneuvers (Class IIa recommendation): leg crossing, squatting, muscle tensing 1
• Compression garments (Class IIa recommendation): abdominal binders and lower extremity compression stockings 1
• Increased salt and fluid intake (Class IIb recommendation): 2-3 liters of fluid daily and increased salt intake (6-10 g/day) unless contraindicated 1, 4
• Sleep position modification: Elevate head of bed during sleep to prevent supine hypertension 1
• Meal modifications: Small, frequent meals to minimize postprandial hypotension 1
• Regular exercise: To prevent deconditioning 1

Step 2: Pharmacological Interventions

For patients with persistent symptoms despite non-pharmacological measures:

1. Midodrine (Class IIa recommendation):

   • Dosage: 10 mg up to 2-4 times daily
   • Mechanism: Alpha-1 agonist that increases vascular tone
   • Demonstrated 22 mmHg increase in standing systolic BP at 10 mg dose
   • FDA-approved for symptomatic orthostatic hypotension 1, 5

2. Droxidopa (Class IIa recommendation):

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

3. Fludrocortisone (Class IIa recommendation):

   • Dosage: 0.05-0.1 mg daily, titrated to 0.1-0.3 mg daily
   • Mechanism: Promotes sodium retention and vessel wall constriction 1
   • Caution: May cause supine hypertension and has concerning long-term effects 3, 4

4. Additional options for refractory cases (Class IIb recommendation):

   • Pyridostigmine
   • Octreotide (especially for severe postprandial hypotension) 1, 6
   • Erythropoietin (25-75 U/kg three times weekly for patients with anemia and severe autonomic dysfunction) 1

Monitoring and Treatment Goals

• Primary goal: Minimize postural symptoms rather than restore normotension 1
• Target BP: <130/80 mmHg for most adults, <130 mmHg for ambulatory older adults (≥65 years) 1
• Regular monitoring: Blood pressure measurements in supine and standing positions to assess treatment effectiveness and monitor for supine hypertension 1
• Follow-up: Every 3 months once stabilized 1

Important Precautions

• Supine hypertension: Monitor carefully, especially with pressor medications like midodrine. Patients should take their last daily dose 3-4 hours before bedtime 1, 5
• Medication interactions: Use caution when combining midodrine with other vasoconstrictors, cardiac glycosides, beta-blockers, or psychopharmacologic agents 5
• Avoid medications that can worsen orthostatic hypotension: opioids, anticholinergics, tricyclic antidepressants 1
• Special populations:
  • Use midodrine cautiously in patients with urinary retention problems, diabetes, renal impairment (starting at 2.5 mg), or hepatic impairment 5
  • Monitor patients on fludrocortisone for increased intraocular pressure, especially those with diabetes or visual problems 5

Patient Education

• Inform patients about over-the-counter medications that can elevate blood pressure (cold remedies, diet aids) 5
• Educate about recognizing prodromal symptoms to take preventive actions 1
• Emphasize the importance of avoiding the supine position after taking medications like midodrine 5

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