What are the treatment options for orthostatic hypotension?

Treatment of Orthostatic Hypotension

The first-line approach for orthostatic hypotension should be non-pharmacological interventions, with pharmacological therapy (midodrine, fludrocortisone, or droxidopa) reserved for patients whose symptoms persist despite lifestyle modifications. 1

Diagnostic Criteria

• 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 1, 2
• Testing should be performed by measuring blood pressure after 5 minutes of sitting/lying and then 1 and/or 3 minutes after standing 1

Non-Pharmacological Management

• Identify and discontinue or modify culprit medications that may cause or worsen orthostatic hypotension 1
• Increase fluid intake to 2-3 liters daily and salt consumption to 6-9g daily if not contraindicated by other conditions 1
• Implement physical counter-maneuvers during symptom onset, such as:
  • Leg crossing, muscle tensing, squatting, and stooping 1
  • Compression garments (thigh-high and abdominal) 1
• Use gradual staged movements when changing posture 1
• Acute water ingestion (≥480 mL) can provide temporary relief, with peak effect occurring 30 minutes after consumption 1
• Elevate the head of the bed (10°) during sleep to prevent supine hypertension 1
• Consume smaller, more frequent meals to reduce post-prandial hypotension 1
• Maintain physical activity and exercise to avoid deconditioning 1

Pharmacological Management

First-Line Medications

• Midodrine:

  • FDA-approved for symptomatic orthostatic hypotension 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, 3
  • Monitor for supine hypertension (BP>200 mmHg systolic) 3
  • Should be used only in patients whose lives are considerably impaired despite standard clinical care 3

• Fludrocortisone:

  • Initial dose: 0.05-0.1 mg daily with individual titration to 0.1-0.3 mg daily 1
  • Acts through sodium retention and vessel wall effects 1
  • Monitor for adverse effects: supine hypertension, hypokalemia, congestive heart failure, and peripheral edema 1, 4
  • Use with caution in patients with heart failure or supine hypertension 4

• 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 1

Second-Line Options

• Pyridostigmine:

  • Beneficial for refractory orthostatic hypotension in elderly patients 1
  • Has fewer side effects than alternatives like fludrocortisone 1
  • Common side effects include nausea, vomiting, abdominal cramping, sweating, salivation, and urinary incontinence 1

• Combination therapy:

  • Consider midodrine and fludrocortisone combination for non-responders to monotherapy 1

Special Considerations

Supine Hypertension Management

• Avoid the supine position; sleep with the head of the bed elevated 1, 5
• Consider shorter-acting antihypertensives at bedtime 1
• For patients with both hypertension and orthostatic hypotension, consider long-acting dihydropyridine calcium channel blockers or RAS inhibitors as first-line therapy 1

Drug Interactions and Precautions

• Monitor blood pressure carefully when midodrine is used with other vasoconstrictors (phenylephrine, ephedrine, dihydroergotamine, phenylpropanolamine, or pseudoephedrine) 3
• Use midodrine cautiously with cardiac glycosides, psychopharmacologic agents, or beta blockers 3
• Use midodrine with caution in patients with urinary retention problems, diabetes, renal impairment, or hepatic impairment 3
• Avoid MAO inhibitors or linezolid with midodrine 3

Treatment Goals

• Focus on minimizing postural symptoms rather than restoring normotension 1
• Balance the benefits of increasing standing blood pressure against the risk of worsening supine hypertension 1
• Continue treatment only for patients who report significant symptomatic improvement 3

Monitoring

• Regularly assess for adverse effects, especially supine hypertension with pressor agents 1
• Monitor for electrolyte abnormalities with fludrocortisone 1
• Evaluate renal function prior to initiating midodrine in patients with renal impairment 3