What is the diagnosis and treatment for orthostatic hypotension?

From the Guidelines

Orthostatic hypotension should be managed with a combination of nonpharmacologic measures, such as ensuring adequate salt intake, avoiding medications that aggravate hypotension, and using compressive garments, along with pharmacologic measures like midodrine or droxidopa, as recommended by the most recent guidelines 1. To diagnose orthostatic hypotension, a reduction of systolic blood pressure of at least 20 mm Hg or 10 mm Hg in diastolic blood pressure within 3 minutes of quiet standing should be detected, as defined by the American Heart Association 1. The therapeutic goal is to minimize postural symptoms rather than to restore normotension, and most patients require both nonpharmacologic and pharmacologic measures, as stated in the 2022 standards of medical care in diabetes 1. Some key nonpharmacologic measures include:

• Ensuring adequate salt intake
• Avoiding medications that aggravate hypotension
• Using compressive garments over the legs and abdomen
• Encouraging physical activity and exercise to avoid deconditioning
• Volume repletion with fluids and salt Pharmacologic measures may involve:
• Midodrine (ProAmatine) 2.5-10 mg three times daily to constrict blood vessels and maintain pressure
• Droxidopa (Northera) 100-600 mg three times daily for persistent symptoms
• Other medications like fludrocortisone (Florinef) 0.1-0.2 mg daily to increase blood volume, as mentioned in previous guidelines 1. It's essential to note that supine blood pressure tends to be much higher in these patients, often requiring treatment of blood pressure at bedtime with shorter-acting drugs that also affect baroreceptor activity, such as guanfacine or clonidine, as recommended in the 2022 guidelines 1.

From the FDA Drug Label

Midodrine hydrochloride tablets are indicated for the treatment of symptomatic orthostatic hypotension (OH) Because midodrine hydrochloride tablets can cause marked elevation of supine blood pressure (BP>200 mmHg systolic), it should be used in patients whose lives are considerably impaired despite standard clinical care, including non-pharmacologic treatment (such as support stockings), fluid expansion, and lifestyle alterations The indication is based on midodrine's effect on increases in 1-minute standing systolic blood pressure, a surrogate marker considered likely to correspond to a clinical benefit.

The diagnosis of orthostatic hypotension is not explicitly stated in the provided drug labels. The treatment for orthostatic hypotension is midodrine hydrochloride tablets, which are indicated for the treatment of symptomatic orthostatic hypotension (OH) 2 2. Key considerations for treatment include:

• The patient's life should be considerably impaired despite standard clinical care
• Non-pharmacologic treatments, such as support stockings, fluid expansion, and lifestyle alterations, should be tried first
• Midodrine hydrochloride tablets should be continued only for patients who report significant symptomatic improvement.

From the Research

Diagnosis of Orthostatic Hypotension

• Orthostatic hypotension is defined as a reduction of at least 20 mm Hg in systolic blood pressure or at least a 10 mm Hg decrease in diastolic blood pressure upon assumption of the upright posture 3, 4
• Diagnosis is based on the history and a thorough clinical examination, with further testing of the heart, kidneys, and autonomic nervous system may be required in selected patients 4
• Symptoms of orthostatic hypotension include dizziness, weakness, blurred vision, tiredness, and loss of consciousness 5, as well as light headedness, fatigue, and lethargy 4

Treatment of Orthostatic Hypotension

• Non-pharmacological methods are the key to management of orthostatic hypotension, including slow position change, increased fluid and sodium intake, compression stockings, and elevation of head of the bed 4
• Pharmacological treatment with fludrocortisone and midodrine should be tried after non-pharmacological methods 3, 4
• Other drugs like desmopresin acetate, xamoterol, erythropoetin, and ocreotide can be used as second-line agents in selected patients 4
• A stepped approach starting with nonpharmacologic measures is recommended, with fludrocortisone, midodrine, indomethacin, and atrial tachypacing recommended in that order for patients in whom nonpharmacologic measures prove insufficient 3
• The goal of treatment is to make the patient as ambulatory and symptom-free as possible without causing supine hypertension 3

Efficacy of Treatments

• Compression bandages, indomethacin, oxilofrine, potassium chloride, and yohimbine have been shown to improve the postural drop 6
• Midodrine and pyridostigmine have been shown to improve the standing blood pressure, but overall worsen the postural drop 6
• Fludrocortisone has been shown to have very low-certainty evidence about its effects on blood pressure, orthostatic symptoms, or adverse events in people with orthostatic hypotension and diabetes or Parkinson disease 7