From the Guidelines
For a 90-year-old female with orthostatic hypotension, initial treatment should focus on non-pharmacological approaches, including adequate hydration, increased salt intake, compression stockings, and physical countermaneuvers, as recommended by the most recent guidelines 1.
Non-Pharmacological Approaches
- Advise adequate hydration with 1.5-2 liters of fluid daily
- Increased salt intake (8-10g/day) if not contraindicated by heart failure or hypertension
- Compression stockings extending to the thigh
- Gradual position changes (sitting for 1-2 minutes before standing)
- Physical countermaneuvers like leg crossing, toe raises, and thigh contractions when standing
Pharmacological Options
If non-pharmacological measures are insufficient, pharmacological options may be considered, including:
- Fludrocortisone (starting at 0.1mg daily, maximum 0.3mg daily) to increase sodium retention and blood volume
- Midodrine (2.5-10mg three times daily, last dose before 6pm) as a vasoconstrictor
- Midodrine and droxidopa are approved by the FDA for the treatment of orthostatic hypotension, as stated in the 2022 guidelines 1
Monitoring and Precautions
- Regular blood pressure monitoring in both supine and standing positions is essential to assess treatment efficacy and avoid complications
- Discontinue medications that may worsen orthostatic hypotension, such as diuretics, alpha-blockers, nitrates, and certain antidepressants, if possible
- Monitor for supine hypertension, electrolyte abnormalities, and heart failure exacerbation, as cautioned in the 2017 guidelines 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 for orthostatic hypotension in a 90-year-old female is midodrine hydrochloride tablets. However, it should be used with caution and only in patients whose lives are considerably impaired despite standard clinical care, including non-pharmacologic treatment. The patient should be evaluated for the potential of supine and sitting hypertension at the beginning of midodrine therapy 2.
From the Research
Treatment Approach
The treatment for orthostatic hypotension in a 90-year-old female involves a stepwise approach, starting with non-pharmacologic measures and progressing to pharmacologic interventions if necessary 3, 4, 5.
Non-Pharmacologic Measures
Non-pharmacologic measures aim to optimize blood volume, decrease postural venous pooling, reduce heat and post-prandial induced vasodilation, emphasize physical conditioning, and minimize nocturnal diuresis 3. These measures may include:
- Reviewing and modifying medications that may aggravate or cause orthostatic hypotension
- Increasing salt and fluid intake
- Wearing compression stockings
- Elevating the head of the bed
- Avoiding standing for long periods
Pharmacologic Interventions
Pharmacologic interventions may be necessary for patients with more severe symptoms, such as falls, syncope, or near-syncope 4, 6. Common medications used to treat orthostatic hypotension include:
- Midodrine: a selective alpha 1-adrenoceptor agonist that increases standing systolic blood pressure and improves standing time and energy level 7
- Droxidopa: a norepinephrine precursor that increases blood pressure and improves symptoms of orthostatic hypotension
- Fludrocortisone: a mineralocorticoid that increases blood volume and improves orthostatic tolerance
- Pyridostigmine: a cholinesterase inhibitor that increases blood pressure and improves symptoms of orthostatic hypotension
Individualized Treatment
Treatment should be individualized based on the underlying cause of orthostatic hypotension, as well as the presence of associated clinical conditions, such as supine hypertension, heart failure, postprandial hypotension, and diabetes 6, 5.