What are the treatment options for orthostatic hypotension?

Treatment of Orthostatic Hypotension

Non-pharmacological measures should be implemented as first-line treatment for orthostatic hypotension, followed by pharmacological therapy with midodrine, fludrocortisone, or droxidopa when symptoms persist despite lifestyle modifications. 1

Non-Pharmacological Management

• Discontinuation or modification of culprit medications that may cause orthostatic hypotension (especially diuretics and vasodilators) is the first step in management 1
• Increase fluid intake to 2-3 liters daily and salt consumption to 6-9g daily if not contraindicated by other conditions such as heart failure or hypertension 1
• Implement physical counter-maneuvers during symptom onset, including leg crossing, muscle tensing, squatting, and stooping 1
• Use compression garments over the legs and abdomen to reduce venous pooling and improve venous return 1
• Elevate the head of the bed (10°) during sleep to prevent nocturnal polyuria, maintain better fluid distribution, and ameliorate nocturnal hypertension 2
• Consume smaller, more frequent meals to reduce post-prandial hypotension 1
• Perform gradual staged movements with postural change to minimize blood pressure drops 1
• Consider acute water ingestion (≥480 mL) for temporary relief, with peak effect occurring 30 minutes after consumption 1
• Maintain physical activity and exercise to avoid deconditioning, which worsens orthostatic intolerance 1

Pharmacological Management

First-Line Medications

• Midodrine: An FDA-approved peripheral selective α1-adrenergic agonist 3

  • Initial dose: 2.5-5mg three times daily 1
  • Can increase standing systolic BP by 15-30 mmHg for 2-3 hours 1
  • Avoid taking the last dose after 6 PM to prevent supine hypertension during sleep 1
  • Monitor for supine hypertension (BP>200 mmHg systolic), which is a significant risk 3
  • Should only be used in patients whose lives are considerably impaired despite standard clinical care 3

• Fludrocortisone: A mineralocorticoid that stimulates renal sodium retention 2

  • Initial dose: 0.05-0.1mg daily, with individual titration to 0.1-0.3mg daily 1
  • Works through sodium retention and vessel wall effects 1
  • Monitor for adverse effects including supine hypertension, hypokalemia, congestive heart failure, and peripheral edema 1

• Droxidopa: FDA-approved for neurogenic orthostatic hypotension 1

  • Particularly effective for orthostatic hypotension due to Parkinson's disease, pure autonomic failure, and multiple system atrophy 1
  • May reduce falls in patients with neurogenic orthostatic hypotension 1

Second-Line Medications

• Pyridostigmine: Consider for refractory orthostatic hypotension, especially in elderly patients 1

  • Has a favorable side effect profile compared to other medications 1
  • Common side effects include nausea, vomiting, abdominal cramping, sweating, salivation, and urinary incontinence 1

• Erythropoietin: Consider for patients with anemia and severe autonomic neuropathy 1

• Desmopressin acetate: May correct nocturnal polyuria and morning orthostatic hypotension 1

Treatment Algorithm

1. Start with non-pharmacological measures for all patients 1
2. If symptoms persist, add pharmacological therapy:
   • For neurogenic orthostatic hypotension: Start with midodrine or droxidopa 1
   • For non-neurogenic orthostatic hypotension: Start with fludrocortisone 1
3. For inadequate response to monotherapy:
   • Consider combination therapy with midodrine and fludrocortisone 1
   • Add pyridostigmine for refractory cases 1
4. For patients with both hypertension and orthostatic hypotension:
   • Consider long-acting dihydropyridine calcium channel blockers or RAS inhibitors 1
   • Use shorter-acting antihypertensives at bedtime to manage supine hypertension 1

Special Considerations

• The therapeutic goal should be to minimize postural symptoms rather than to restore normotension 1
• Balance the benefits of increasing standing blood pressure against the risk of worsening supine hypertension 1
• Regularly monitor for adverse effects, especially supine hypertension with pressor agents and electrolyte abnormalities with fludrocortisone 1
• For diabetic patients with orthostatic hypotension, assess for cardiovascular autonomic neuropathy 1
• Avoid medications that can exacerbate orthostatic hypotension when possible, including psychotropic drugs, diuretics, and α-adrenoreceptor antagonists 1
• Use midodrine with caution in patients with urinary retention problems, as it acts on the alpha-adrenergic receptors of the bladder neck 3
• Use midodrine cautiously in patients with renal impairment, with a starting dose of 2.5 mg 3

By following this comprehensive approach to orthostatic hypotension management, most patients can achieve significant symptom improvement and better quality of life.