How do I treat orthostatic hypotension?

Treatment of Orthostatic Hypotension

Non-pharmacological approaches should be pursued as first-line treatment for orthostatic hypotension before considering pharmacological therapy. 1

Definition and Diagnosis

• Orthostatic hypotension is defined as a sustained reduction in systolic blood pressure >20 mmHg or diastolic blood pressure >10 mmHg within 3 minutes of standing 2
• Before starting or intensifying blood pressure-lowering medication, test for orthostatic hypotension by measuring blood pressure after 5 minutes of sitting/lying and then 1 and/or 3 minutes after standing 1

Non-Pharmacological Management

First-Line Interventions

• Identify and discontinue medications that exacerbate orthostatic hypotension (psychotropic drugs, diuretics, α-adrenoreceptor antagonists) 1
• Increase fluid and salt intake if not contraindicated by other conditions 1, 3
• Implement physical counter-maneuvers (leg-crossing, stooping, squatting, tensing muscles) 1, 4
• Recommend gradual staged movements with postural change 1
• Advise acute water ingestion (≥480 mL) for temporary relief, with peak effect occurring 30 minutes after consumption 1, 5
• Recommend use of elastic compression garments over legs and abdomen 1, 4
• Suggest sleeping with head-up bed position 1, 6
• Recommend smaller, more frequent meals to reduce post-prandial hypotension 1, 4
• Encourage physical activity and exercise to avoid deconditioning 1

Pharmacological Management

When to Consider Medication

• Consider pharmacological treatment when non-pharmacological measures fail to adequately control symptoms 1
• The therapeutic goal is to minimize postural symptoms rather than to restore normotension 1

First-Line Medications

1. Midodrine

   • FDA-approved for symptomatic orthostatic hypotension 7
   • Peripheral selective α1-adrenergic agonist that exerts pressor effect through arteriolar and venous constriction 7
   • Dosing: Start with 2.5-5 mg, up to 10 mg three times daily (last dose no later than 6 PM to avoid supine hypertension) 1, 7
   • Monitor for adverse effects: supine hypertension, pilomotor reactions, pruritus, bradycardia, gastrointestinal symptoms, urinary retention 1, 7

2. Fludrocortisone

   • Increases plasma volume with resultant improvement in orthostatic symptoms 1
   • Use with caution when supine hypertension is present 1
   • Monitor for side effects: edema, hypokalemia, headache, and potential adrenal suppression with doses >0.3 mg daily 1

3. Droxidopa

   • FDA-approved for neurogenic orthostatic hypotension 1, 3
   • Particularly beneficial in Parkinson disease, pure autonomic failure, and multiple system atrophy 1
   • Monitor for supine hypertension, headache, dizziness, and nausea 1

Special Considerations

Hypertension and Orthostatic Hypotension

• For patients with both hypertension and orthostatic hypotension, consider:
  • Long-acting dihydropyridine calcium channel blockers as first-line therapy 3
  • RAS inhibitors (ACE inhibitors or ARBs) as alternative first-line agents 3
  • Switching medications that worsen orthostatic hypotension rather than simply reducing the dose 1

Diabetes and Orthostatic Hypotension

• In diabetic patients with orthostatic hypotension, assess for cardiovascular autonomic neuropathy 1
• Consider α-lipoic acid which may be effective for painful diabetic neuropathy and potentially beneficial for autonomic function 1
• Avoid medications that can aggravate hypotension in diabetic patients with urinary retention problems 1, 7

Treatment Algorithm

1. Initial Assessment:

   • Confirm orthostatic hypotension diagnosis with proper BP measurements 1, 2
   • Identify and address reversible causes 8

2. First Step:

   • Implement all appropriate non-pharmacological measures 1, 6
   • Discontinue or modify medications that may cause or worsen orthostatic hypotension 1, 3

3. Second Step (if symptoms persist):

   • Start with midodrine (10 mg up to three times daily, with last dose before 6 PM) 1, 7
   • Monitor for supine hypertension and adjust dosing as needed 7

4. Third Step (if inadequate response):

   • Add fludrocortisone or consider droxidopa 1
   • For patients with both hypertension and orthostatic hypotension, select antihypertensives with minimal impact on orthostatic BP (long-acting CCBs or RAS inhibitors) 3

5. Ongoing Management:

   • Regular monitoring for supine hypertension 7
   • Adjust therapy based on symptomatic response rather than targeting specific BP values 2

Pitfalls and Caveats

• Supine hypertension is a common adverse effect of medications used to treat orthostatic hypotension; advise patients to sleep with head of bed elevated 1, 7
• Midodrine should be used only in patients whose lives are considerably impaired despite standard clinical care 7
• Avoid taking orthostatic hypotension medications close to bedtime to minimize nighttime supine hypertension 7
• Be cautious when using midodrine concomitantly with other vasoconstrictors, cardiac glycosides, or medications that reduce heart rate 7
• Use midodrine with caution in patients with renal impairment, starting with a lower dose (2.5 mg) 7