What are the guidelines and measures for managing orthostatic hypotension?

Management of Orthostatic Hypotension: Guidelines and Measures

The management of orthostatic hypotension should follow a stepwise approach beginning with non-pharmacological interventions, followed by pharmacological therapy only when symptoms persist despite conservative measures. 1, 2

Definition and Diagnosis

• 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 2, 3
• Testing should be performed by measuring blood pressure after 5 minutes of sitting/lying and then at 1 and/or 3 minutes after standing 2, 3
• Common symptoms include dizziness, lightheadedness, weakness, fatigue, and syncope due to cerebral hypoperfusion 3

Non-Pharmacological Management (First-Line)

• Maintain adequate hydration with 2-3 L of fluids per day 1, 2
• Increase salt intake to 6-10g of NaCl daily (if not contraindicated by other conditions such as heart failure or hypertension) 1, 2
• Implement physical counterpressure maneuvers during symptom onset:
  • Leg crossing, muscle tensing, squatting, and stooping 1, 2
  • These techniques help reduce venous pooling and maintain cerebral perfusion 2
• Use compression garments:
  • Abdominal binders and/or thigh-high compression stockings to reduce venous pooling 1, 2
• Acute water ingestion (≥480 mL) for temporary relief, with peak effect at 30 minutes 2
• Sleep with head of bed elevated (10°) to:
  • Prevent nocturnal polyuria
  • Maintain better fluid distribution
  • Ameliorate nocturnal hypertension 1, 2
• Consume smaller, more frequent meals to reduce post-prandial hypotension 2
• Maintain physical activity and exercise to avoid deconditioning 2
• Discontinue or modify culprit medications when possible (diuretics, vasodilators, psychotropic drugs, α-adrenoreceptor antagonists) 2, 3

Pharmacological Management (When Non-Pharmacological Measures Fail)

First-Line Medications

• Midodrine (alpha-1 agonist) 1, 2, 4

  • Dosage: 2.5-5mg initially, titrate to 5-20 mg three times daily
  • Timing: Last dose should be taken before 6 PM to prevent supine hypertension
  • Mechanism: Acts through arteriolar and venous constriction
  • Effect: Increases standing systolic BP by 15-30 mmHg for 2-3 hours
  • FDA indication: Treatment of symptomatic orthostatic hypotension in patients whose lives are considerably impaired despite standard clinical care

• Fludrocortisone (mineralocorticoid) 1, 2

  • Dosage: 0.05-0.1 mg initially, titrate to 0.1-0.3 mg once daily
  • Mechanism: Stimulates renal sodium retention and expands fluid volume
  • Monitor for: Supine hypertension, hypokalemia, congestive heart failure, peripheral edema

• Droxidopa 2

  • FDA-approved for neurogenic orthostatic hypotension
  • Particularly beneficial in Parkinson's disease, pure autonomic failure, and multiple system atrophy
  • May reduce falls

Second-Line/Adjunctive Medications

• Desmopressin for nocturnal polyuria 1, 2
• Octreotide for post-prandial hypotension 1
• Pyridostigmine for neurogenic OH, especially in refractory cases 1, 2
• Erythropoietin in patients with anemia and severe autonomic neuropathy 1, 2

Special Considerations and Monitoring

• Treatment goal: Minimize postural symptoms rather than restore normotension 2
• Balance benefits of increasing standing blood pressure against risk of worsening supine hypertension 2
• For patients with both hypertension and orthostatic hypotension:
  • Consider long-acting dihydropyridine calcium channel blockers or RAS inhibitors as first-line therapy 2
  • Shorter-acting antihypertensives at bedtime may help manage supine hypertension 2
• For refractory cases, consider combination therapy (e.g., midodrine and fludrocortisone) 2
• Regular monitoring for adverse effects, especially supine hypertension with pressor agents 2
• Beta-blockers may be detrimental in dysautonomic syndromes 1

Common Pitfalls to Avoid

• Failing to identify and address reversible causes (medication effects, volume depletion) 2
• Taking the last dose of midodrine after 6 PM, which can cause dangerous supine hypertension during sleep 2
• Simply reducing the dose of BP-lowering medications rather than switching to an alternative therapy 2
• Overlooking non-pharmacological interventions before initiating drug therapy 1, 2
• Inadequate monitoring for supine hypertension and electrolyte abnormalities 2