From the Guidelines
Orthostatic hypotension should be managed with a combination of lifestyle modifications and pharmacological interventions, prioritizing midodrine and droxidopa as first-line treatments, as recommended by the most recent guidelines 1. To manage orthostatic hypotension, start by implementing lifestyle modifications:
- Rise slowly from lying or sitting positions
- Stay well-hydrated by drinking 2-3 liters of water daily
- Increase salt intake (unless contraindicated by other conditions)
- Wear compression stockings
- Avoid alcohol and large meals If symptoms persist, medications may be necessary. First-line pharmacological options include:
- Midodrine (2.5-10 mg three times daily), an alpha-1 agonist that constricts blood vessels
- Droxidopa (100-600 mg three times daily) for neurogenic orthostatic hypotension These medications should be taken early in the day to avoid nighttime hypertension, with the last dose at least 3-4 hours before bedtime. Underlying causes should be addressed, such as adjusting medications that may contribute to hypotension (like antihypertensives, antidepressants, or diuretics) 1. Orthostatic hypotension occurs because of inadequate compensatory mechanisms that normally increase vascular tone and heart rate when standing, often due to autonomic nervous system dysfunction, dehydration, medication effects, or aging. Key considerations in treatment include minimizing postural symptoms rather than restoring normotension, and using nonpharmacologic measures in conjunction with pharmacologic interventions 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 diagnosis of orthostatic hypotension is not explicitly stated in the provided drug labels. The treatment for orthostatic hypotension includes:
- Midodrine hydrochloride tablets for symptomatic orthostatic hypotension
- Non-pharmacologic treatment, such as:
- Support stockings
- Fluid expansion
- Lifestyle alterations Midodrine should be used in patients whose lives are considerably impaired despite standard clinical care 2.
From the Research
Diagnosis of Orthostatic Hypotension
- Orthostatic hypotension is defined as a decrease in systolic blood pressure of 20 mm Hg or a decrease in diastolic blood pressure of 10 mm Hg within three minutes of standing when compared with blood pressure from the sitting or supine position 3, 4, 5.
- Symptoms of orthostatic hypotension include dizziness, lightheadedness, blurred vision, weakness, fatigue, nausea, palpitations, and headache 3, 4.
- Diagnosis is confirmed by performing a bedside simplified Schellong test, which consists of blood pressure and heart rate measurements after five minutes in the supine position and three minutes after moving to a standing position 4.
- Head-up tilt-table testing can aid in confirming a diagnosis of suspected orthostatic hypotension when standard orthostatic vital signs are nondiagnostic 3, 4.
Treatment of Orthostatic Hypotension
- Goals of treatment involve improving hypotension without excessive supine hypertension, relieving orthostatic symptoms, and improving standing time 3.
- Nonpharmacologic treatment should be offered to all patients, including dietary modifications, compression garments, physical maneuvers, and avoiding environments that exacerbate symptoms 3, 4, 5.
- Pharmacologic therapies proven to be beneficial include fludrocortisone, midodrine, and pyridostigmine 3, 6, 7.
- First-line medications include midodrine and droxidopa, although fludrocortisone may be used in certain cases 4, 5, 7.
- Treatment should be individualized according to the severity, underlying cause, 24-hour blood pressure profile, and associated coexisting conditions 5.