What is the treatment for orthostatic hypotension?

Treatment of Orthostatic Hypotension

The treatment of orthostatic hypotension should begin with non-pharmacological measures, followed by pharmacological therapy with midodrine, fludrocortisone, or droxidopa when symptoms persist despite conservative management. 1, 2

Initial Approach

• Identify and eliminate exacerbating factors, including discontinuing medications that worsen orthostatic hypotension and correcting volume depletion 1
• The goal of treatment is to minimize postural symptoms rather than restore normotension 1, 2
• Assess for underlying causes such as neurogenic vs. non-neurogenic etiologies to guide treatment approach 3

Non-Pharmacological Management (First-Line)

• Increase fluid and salt intake if not contraindicated by other conditions (e.g., heart failure, hypertension) 1, 2
• Implement physical counter-maneuvers such as leg-crossing, stooping, squatting, and tensing muscles 2
• Use compression garments over legs and abdomen to reduce venous pooling 1
• Recommend gradual staged movements with postural change to minimize blood pressure drops 1, 2
• Advise acute water ingestion (≥480 mL) for temporary relief, with peak effect occurring 30 minutes after consumption 2
• Suggest smaller, more frequent meals to reduce post-prandial hypotension 2
• Encourage physical activity and exercise to avoid deconditioning 2
• Elevate the head of the bed during sleep to prevent supine hypertension 4

Pharmacological Management

When to Consider Medications

• Initiate pharmacological treatment when non-pharmacological measures fail to adequately control symptoms 2

First-Line Medications

• Midodrine:

  • Dosing: 2.5-10 mg three times daily 1
  • FDA-approved for symptomatic orthostatic hypotension 5
  • Should be used in patients whose lives are considerably impaired despite standard clinical care 5
  • Caution: Can cause marked elevation of supine blood pressure (>200 mmHg systolic) 5
  • Last dose should be taken 3-4 hours before bedtime to minimize nighttime supine hypertension 5
  • Monitor for potential interactions with other vasoconstrictors and cardiac glycosides 5

• Fludrocortisone:

  • Dosing: 0.05-0.1 mg daily, titrate to 0.1-0.3 mg daily 1
  • Volume-expanding mineralocorticoid that enhances sodium retention 6
  • May be used in combination with midodrine in severe cases 6
  • Monitor for potential side effects including edema, hypokalemia, and worsening of supine hypertension 5

• Droxidopa:

  • FDA-approved alternative specifically for neurogenic orthostatic hypotension 1
  • Consider when midodrine or fludrocortisone are ineffective or contraindicated 2

Special Considerations

• For patients with both hypertension and orthostatic hypotension, consider long-acting dihydropyridine calcium channel blockers or RAS inhibitors as first-line antihypertensive therapy 2
• In diabetic patients, assess for cardiovascular autonomic neuropathy 2
• Monitor for supine hypertension, especially with vasopressor medications 5
• Use caution with midodrine in patients with urinary retention problems, as it acts on alpha-adrenergic receptors of the bladder neck 5
• Avoid using midodrine concomitantly with MAO inhibitors or linezolid 5
• For patients with refractory symptoms, combination therapy may be necessary 7

Monitoring and Follow-up

• Evaluate treatment efficacy by assessing symptom improvement and functional status rather than targeting specific blood pressure values 7
• Continue midodrine only for patients who report significant symptomatic improvement 5
• Monitor for supine hypertension by checking blood pressure in lying, sitting, and standing positions 5