From the Guidelines
The workup for a patient experiencing an episode of orthostatic hypotension should begin with a thorough history and physical examination, focusing on potential causes such as dehydration, medication effects, or underlying medical conditions, as recommended by the most recent guidelines 1. The initial evaluation should include:
- Orthostatic vital signs, measuring blood pressure and heart rate while lying down, sitting, and standing
- Basic laboratory tests, including complete blood count, comprehensive metabolic panel, thyroid function tests, and morning cortisol levels to rule out anemia, electrolyte abnormalities, and endocrine disorders
- An ECG to assess for cardiac arrhythmias or conduction abnormalities If the patient is taking medications known to cause hypotension, medication review and possible adjustment should be considered. For most patients with a single episode, non-pharmacological interventions like:
- Adequate hydration
- Salt intake
- Compression stockings
- Slow positional changes may be sufficient. If symptoms persist or are severe, further evaluation may include:
- Tilt-table testing
- Autonomic function tests
- Specialty referral to cardiology or neurology The workup should be tailored to the patient's age, comorbidities, and clinical presentation, as postural hypotension can result from various physiological mechanisms including impaired vasoconstriction, reduced cardiac output, or autonomic dysfunction, as noted in the latest standards of care in diabetes-2025 1. Key considerations in the management of orthostatic hypotension include:
- Ensuring adequate salt intake
- Avoiding medications that aggravate hypotension
- Using compressive garments over the legs and abdomen
- Encouraging physical activity and exercise to avoid deconditioning
- Volume repletion with fluids and salt is critical, as emphasized in recent studies 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Diagnosis and Assessment
- Orthostatic hypotension is defined as a reduction of at least 20 mm Hg in systolic blood pressure or at least a 10 mm Hg decrease in diastolic blood pressure upon assumption of the upright posture 2
- A thorough assessment is needed to draw an appropriate management plan, including review of medications, identification of underlying causes, and evaluation of symptoms 3
Non-Pharmacologic Measures
- Non-pharmacologic measures are recommended as the first line of treatment, including:
- Reviewing and modifying medications that may aggravate or cause orthostatic hypotension 4
- Optimizing blood volume, decreasing postural venous pooling, reducing heat and post-prandial induced vasodilation, emphasizing physical conditioning, and minimizing nocturnal diuresis 4
- Using compression devices, dietary modifications, and postural aids 3
- Avoiding large carbohydrate-rich meals, limiting alcohol consumption, maintaining adequate hydration, adding salt to foods, and using compression stockings, tilt-table exercises, or abdominal binders 5
Pharmacologic Measures
- Pharmacologic measures may be necessary for patients who do not respond to non-pharmacologic measures, including:
- Fludrocortisone, midodrine, indomethacin, and atrial tachypacing 2
- Midodrine and fludrocortisone are the most prescribed and best studied pharmacologic therapies 3
- Pyridostigmine, atomoxetine, and droxidopa may be considered for patients who do not respond to first-line therapies 3, 5
- Yohimbine remains an investigational agent 3
Treatment Approach
- A stepped approach to treatment is recommended, starting with non-pharmacologic measures and progressing to pharmacologic measures as needed 2, 4
- A personalized management plan should be developed for each patient, taking into account their individual needs and underlying causes of orthostatic hypotension 3
- A multidisciplinary team may be required to manage patients with multiple comorbidities and polypharmacy 3