What are the treatment options for orthostatic (postural) hypotension?

From the Guidelines

The most effective treatment options for orthostatic hypotension include midodrine, fludrocortisone, droxidopa, and pyridostigmine, as well as non-pharmacological measures such as increased salt and fluid intake, compression stockings, and physical counter-pressure maneuvers, as recommended by the 2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope 1.

Treatment Options

The treatment of orthostatic hypotension should be individualized based on the severity of symptoms, underlying cause of orthostatic hypotension, and potential side effects.

• Midodrine (2.5-10mg three times daily) is an alpha-1 agonist that increases peripheral vascular resistance and should be taken during waking hours only, with the last dose at least 4 hours before bedtime to avoid supine hypertension 1.
• Fludrocortisone (0.1-0.3mg daily) is a mineralocorticoid that increases sodium retention and blood volume, but requires monitoring for hypokalemia and edema 1.
• Droxidopa (100-600mg three times daily) is a norepinephrine precursor that helps maintain blood pressure upon standing and is particularly useful in neurogenic orthostatic hypotension 1.
• Pyridostigmine (30-60mg three times daily) is an acetylcholinesterase inhibitor that enhances sympathetic ganglionic transmission specifically during standing 1.

Non-Pharmacological Measures

Non-pharmacological measures should be tried first, including:

• Increased salt and fluid intake, with a recommended salt supplementation of 6 to 9 g (100 to 150 mmol; about 1 to 2 teaspoons) of salt per day 1.
• Compression stockings, which should be at least thigh high and preferably include the abdomen, as shorter garments have not been proved to be beneficial 1.
• Physical counter-pressure maneuvers, such as leg crossing, lower body muscle tensing, and maximal force handgrip, which can increase blood pressure and improve orthostatic tolerance 1.

Additional Considerations

Treatment should be carefully monitored for supine hypertension, a common concern with these medications.

• The use of carbidopa in patients with Parkinson disease may decrease the effectiveness of droxidopa 1.
• The long-term effects of increased salt and fluid intake, including the benefits and risks, are unknown and should be carefully considered in patients with a history of hypertension, renal disease, heart failure, or cardiac dysfunction 1.

From the FDA Drug Label

Midodrine hydrochloride tablets are indicated for the treatment of symptomatic orthostatic hypotension (OH) Because midodrine hydrochloride tablets can cause marked elevation of supine blood pressure (BP>200 mmHg systolic), it should be used in patients whose lives are considerably impaired despite standard clinical care, including non-pharmacologic treatment (such as support stockings), fluid expansion, and lifestyle alterations

The treatment options for orthostatic (postural) hypotension include:

• Midodrine: a medication that can help increase blood pressure in patients with symptomatic orthostatic hypotension
• Non-pharmacologic treatment: such as
  • Support stockings
  • Fluid expansion
  • Lifestyle alterations It is recommended to use midodrine only in patients who have not responded to standard clinical care and whose lives are considerably impaired despite these efforts 2

From the Research

Treatment Options for Orthostatic Hypotension

The treatment options for orthostatic hypotension can be categorized into non-pharmacological measures and pharmacological treatments.

• Non-pharmacological measures: These are often tried initially and may be sufficient for milder cases 3. They include:

  • Reviewing and modifying medications that may aggravate or cause orthostatic hypotension
  • Increasing fluid and salt intake
  • Venous compression methods
  • Optimizing blood volume
  • Decreasing postural venous pooling
  • Reducing heat and post-prandial induced vasodilation
  • Emphasizing physical conditioning
  • Minimizing nocturnal diuresis

• Pharmacological treatments: These are used when non-pharmacological measures are not sufficient, especially in cases with severe symptoms such as falls, syncope, or near-syncope 4, 5, 6, 7. Common medications used include:

  • Midodrine: a prodrug that increases 1-minute standing systolic blood pressure and improves standing time and energy level 5
  • Fludrocortisone: a mineralocorticoid that increases blood volume and blood pressure, considered first- or second-line pharmacological therapy for orthostatic hypotension 4, 6
  • Pyridostigmine
  • Droxidopa: only midodrine and droxidopa have received FDA approval for the treatment of orthostatic hypotension 7

Considerations for Treatment

The choice of treatment should be individualized according to the severity, underlying cause, 24-hour blood pressure profile, and associated coexisting conditions 4. It is also important to consider the risk of supine hypertension, which can be associated with certain medications such as midodrine, and to take measures to reduce this risk, such as taking the final daily dose at least 4 hours before bedtime 5.