What is the initial management for a patient presenting with orthostatic hypotension?

Initial Management of Orthostatic Hypotension

The initial management for a patient presenting with orthostatic hypotension should focus on identifying and addressing reversible causes, implementing non-pharmacological measures, and initiating pharmacological therapy only when necessary. 1

Diagnosis and Assessment

• Orthostatic hypotension is defined as a decrease in systolic blood pressure of ≥20 mm Hg or diastolic blood pressure of ≥10 mm Hg within 3 minutes of standing from a supine or seated position 2, 3
• Initial assessment should include measurement of blood pressure after 5 minutes of lying/sitting and then at 1 and/or 3 minutes after standing to confirm the diagnosis 1
• Evaluate for reversible causes including medication effects, volume depletion, and endocrine disorders 1
• Review all current medications that may contribute to orthostatic hypotension, particularly diuretics, vasodilators, and psychoactive drugs 4

Initial Non-Pharmacological Management

• Increase fluid intake to 2-3 liters daily and salt consumption to 6-9g daily if not contraindicated by other conditions (e.g., heart failure, hypertension) 1
• Implement physical counter-maneuvers during symptom onset, such as leg-crossing, muscle tensing, squatting, and stooping 1
• Recommend smaller, more frequent meals to reduce post-prandial hypotension 1
• Advise acute water ingestion (≥480 mL) for temporary relief, with peak effect occurring 30 minutes after consumption 1
• Recommend compression garments, including thigh-high stockings and abdominal compression 1
• Suggest gradual staged movements with postural change to minimize symptoms 1
• Elevate the head of the bed during sleep to help prevent supine hypertension 1

Medication Adjustments

• Modify or discontinue hypotensive drug treatment for concomitant conditions 2
• Consider long-acting dihydropyridine calcium channel blockers or RAS inhibitors as first-line therapy for patients with both hypertension and orthostatic hypotension 1
• Avoid taking the last dose of any pressor agent after 6 PM to prevent supine hypertension during sleep 1

Pharmacological Management

• Consider pharmacological treatment only when non-pharmacological measures fail to adequately control symptoms 1
• First-line medications include:
  • Midodrine (alpha-1 agonist): Initial dose 2.5-5mg three times daily, can increase standing systolic BP by 15-30 mmHg for 2-3 hours 1, 5
  • Fludrocortisone (mineralocorticoid): Initial dose 0.05-0.1mg daily, works by increasing plasma volume 1
  • Droxidopa: Particularly effective for neurogenic orthostatic hypotension 1

Special Considerations

• The therapeutic goal should be minimizing postural symptoms rather than restoring normotension 1
• Regular monitoring for adverse effects is essential, especially supine hypertension with pressor agents and electrolyte abnormalities with fludrocortisone 1
• For patients who do not respond to monotherapy, consider combination therapy with midodrine and fludrocortisone 1
• Midodrine should be used only in patients whose lives are considerably impaired despite standard clinical care, as it can cause marked elevation of supine blood pressure 5

Monitoring and Follow-up

• Assess symptomatic improvement rather than targeting arbitrary blood pressure values 6
• Monitor for supine hypertension, which is a common adverse effect of pressor agents 5
• Continue treatment only for patients who report significant symptomatic improvement 5