Can Brintellix (vortioxetine) cause orthostatic hypotension?

Brintellix (Vortioxetine) and Orthostatic Hypotension

Brintellix (vortioxetine) is not commonly associated with orthostatic hypotension or postural giddiness, unlike many other psychiatric medications. While orthostatic hypotension is a known side effect of many antidepressants, particularly tricyclic antidepressants and some SSRIs, vortioxetine does not have strong evidence linking it to this adverse effect.

Understanding Orthostatic Hypotension

Orthostatic hypotension is defined as:

• A decrease in systolic blood pressure of ≥20 mmHg or diastolic blood pressure of ≥10 mmHg within 3 minutes of standing from a supine or seated position 1
• Can cause symptoms such as dizziness, light-headedness, weakness, fatigue, and syncope 2
• May be accompanied by postural giddiness, which is the sensation of unsteadiness when changing positions 2

Medications Associated with Orthostatic Hypotension

Psychiatric medications commonly associated with orthostatic hypotension include:

• Phenothiazines 3
• Tricyclic antidepressants 3, 4
• Monoamine oxidase inhibitors 3

Other medications that can cause orthostatic hypotension:

• Antihypertensives, particularly alpha-1 blockers, adrenergic blockers, and centrally acting drugs 3
• Diuretics (through volume depletion) 2, 3
• Vasodilators 1

Vortioxetine and Orthostatic Effects

Unlike many other antidepressants, vortioxetine (Brintellix) has not been prominently associated with orthostatic hypotension in clinical guidelines or drug safety profiles. The medication works through multiple mechanisms including serotonin reuptake inhibition and receptor modulation, but does not have the strong alpha-adrenergic blocking properties that typically cause orthostatic hypotension in other antidepressants.

Risk Assessment and Monitoring

For patients taking any psychiatric medication, including vortioxetine:

• Measure blood pressure after 5 minutes of lying/sitting and then at 1 and/or 3 minutes after standing to check for orthostatic changes 2, 1
• Be particularly vigilant in monitoring elderly patients, who are more susceptible to orthostatic hypotension 4, 5
• Watch for symptoms such as dizziness, light-headedness, weakness, or syncope 2

Management of Medication-Induced Orthostatic Hypotension

If orthostatic hypotension does occur with any medication:

Non-Pharmacological Approaches:

• Increase fluid intake to 2-3 liters daily and salt consumption if not contraindicated 6, 1
• Implement physical counter-maneuvers during symptom onset (leg-crossing, muscle tensing) 6, 1
• Recommend smaller, more frequent meals to reduce post-prandial hypotension 2, 1
• Suggest gradual staged movements with postural change 6, 1
• Consider compression garments for the legs and abdomen 6, 1

Pharmacological Management (if needed):

• Consider midodrine, an alpha-1 agonist, for severe cases 2, 6
• Fludrocortisone may be used in persistent cases 6, 7
• Droxidopa is FDA-approved for neurogenic orthostatic hypotension 2, 6

Clinical Implications

When prescribing antidepressants:

• Consider vortioxetine as a potentially favorable option for patients with risk factors for orthostatic hypotension 5
• Be aware that fluoxetine has been used to treat refractory orthostatic hypotension in some cases 8
• Monitor all patients on psychiatric medications for orthostatic changes, even those on medications not typically associated with this side effect 4

Conclusion

While orthostatic hypotension is a common side effect of many psychiatric medications, Brintellix (vortioxetine) does not have strong evidence linking it to postural giddiness or orthostatic hypotension. However, individual responses to medications can vary, and monitoring for this potential side effect remains prudent clinical practice, particularly in elderly patients or those with other risk factors for orthostatic hypotension.