What is the treatment for orthostatic hypotension?

Treatment of Orthostatic Hypotension

The first-line treatment for orthostatic hypotension includes non-pharmacological measures, with midodrine being the primary pharmacological intervention for symptomatic patients who do not respond to conservative management. 1, 2

Initial Assessment and Non-Pharmacological Management

• Identify and discontinue medications that exacerbate orthostatic hypotension, such as psychotropic drugs, diuretics, and α-adrenoreceptor antagonists 3, 1
• Correct volume depletion through increased fluid and salt intake if not contraindicated 3, 1
• Implement behavioral strategies:
  • Gradual staged movements when changing posture 3, 1
  • Physical counter-maneuvers (leg-crossing, stooping, squatting, tensing muscles) 3, 1
  • Head-up bed position during sleep 3, 1
  • Use of portable folding chairs 3
  • Rapid water drinking 1
  • Avoidance of large carbohydrate-rich meals 3
• Apply elastic compression garments over legs and abdomen 3, 1

Pharmacological Treatment

First-Line Medication:

• Midodrine (peripheral selective α1-adrenergic agonist) 3, 1, 2
  • Dosing: Start with 2.5 mg, titrate up to 10 mg three times daily 1, 2
  • First dose should be taken before arising 3
  • Avoid use several hours before planned recumbency 3, 2
  • FDA-approved specifically for symptomatic orthostatic hypotension 2
  • Monitor for supine hypertension, which can be managed by preventing the patient from becoming fully supine 2

Alternative Medications:

• Fludrocortisone (0.05-0.1 mg daily, titrate to 0.1-0.3 mg daily) 1, 4

  • Volume expander that enhances sodium retention 4
  • Monitor for supine hypertension, edema, and hypokalemia 2

• Droxidopa (FDA-approved alternative for neurogenic orthostatic hypotension) 1

  • Similar precautions regarding timing of doses to avoid supine hypertension 2

Special Considerations

• The therapeutic goal is to minimize postural symptoms rather than to restore normotension 3, 1
• Weigh potential risks of medications against possible benefits, particularly regarding supine hypertension 3
• For patients with both hypertension and orthostatic hypotension, long-acting dihydropyridine calcium channel blockers or RAS inhibitors are preferred antihypertensive agents 5
• Beta-blockers can be used to treat resting tachycardia associated with cardiovascular autonomic neuropathy but should generally be avoided in patients with orthostatic hypotension unless there are compelling indications 3, 5
• Use midodrine with caution in patients with:
  • Urinary retention problems 2
  • Renal impairment (starting dose of 2.5 mg recommended) 2
  • Hepatic impairment 2
  • Concomitant use of cardiac glycosides, psychopharmacologic agents, or beta blockers 2

Monitoring and Follow-up

• Assess for supine hypertension, especially when initiating treatment 2
• Continue midodrine only for patients who report significant symptomatic improvement 2
• Monitor blood pressure carefully when midodrine is used with other vasoconstrictors 2
• Evaluate heart rate for bradycardia, which may occur due to vagal reflex 2
• Assess renal function prior to initiating midodrine 2

Treatment Algorithm Based on Severity

1. Mild symptoms: Non-pharmacological measures alone 3, 1
2. Moderate symptoms: Non-pharmacological measures plus consideration of volume expanders 3, 1
3. Severe symptoms: Add pharmacological treatment with midodrine as first-line therapy 3, 1, 2
4. Refractory symptoms: Consider combination therapy or alternative agents 1, 4

Remember that treatment should be tailored based on the underlying cause of orthostatic hypotension and the presence of comorbidities 6, 7.