How is orthostatic hypotension managed?

Management of Orthostatic Hypotension

The management of orthostatic hypotension should prioritize non-pharmacological interventions first, followed by pharmacological therapies only when symptoms persist, with the goal of minimizing postural symptoms rather than restoring normotension. 1, 2

Definition and Diagnosis

• Orthostatic hypotension is defined as a decrease in systolic blood pressure of 20 mmHg or more, or a decrease in diastolic blood pressure of 10 mmHg or more within three minutes of standing compared to the sitting or supine position 3
• 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 (First-Line)

Lifestyle Modifications

• Increase fluid intake to 2-3 liters daily and salt consumption to 6-9g daily if not contraindicated by other conditions 1, 2
• Implement smaller, more frequent meals to reduce post-prandial hypotension 1
• Encourage physical activity and exercise to avoid deconditioning, which worsens orthostatic intolerance 4, 1
• Elevate the head of the bed (10°) during sleep to prevent supine hypertension 1, 2

Physical Countermeasures

• Teach physical counter-maneuvers such as leg-crossing, stooping, squatting, and tensing muscles to help manage symptoms during onset 1, 2
• Recommend acute water ingestion (≥480 mL) for temporary relief, with peak effect occurring 30 minutes after consumption 1
• Use compression garments, including thigh-high stockings and abdominal compression, to reduce venous pooling 1, 2
• Advise gradual positional changes to minimize symptoms 1

Pharmacological Management (Second-Line)

First-Line Medications

• Midodrine: An FDA-approved alpha-1 agonist that increases standing systolic BP by 15-30 mmHg for 2-3 hours 5

  • Initial dose: 2.5-5mg three times daily 1
  • Maximum dose: Up to 10mg three times daily 5
  • Timing: Last dose should be taken at least 3-4 hours before bedtime to minimize nighttime supine hypertension 5
  • Contraindications: Severe cardiac disease, acute renal disease, urinary retention, pheochromocytoma, thyrotoxicosis 5

• Fludrocortisone: Acts through sodium retention and vessel wall effects 1

  • Initial dose: 0.05-0.1mg daily 1, 2
  • Titration: Individual titration to 0.1-0.3mg daily 1
  • Monitor for adverse effects: Supine hypertension, hypokalemia, congestive heart failure, peripheral edema 1

• Droxidopa: FDA-approved for neurogenic orthostatic hypotension 4, 1

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

Additional Pharmacological Options

• Pyridostigmine: Consider for refractory orthostatic hypotension, particularly in elderly patients 1
• Erythropoietin: Consider for patients with anemia and severe autonomic neuropathy 1
• Desmopressin: May correct nocturnal polyuria and morning orthostatic hypotension 1
• Octreotide: Consider for post-prandial hypotension 2

Special Considerations

Medication Adjustments

• Discontinue or modify culprit medications that may cause or worsen orthostatic hypotension, particularly diuretics, vasodilators, psychotropic drugs, and α-adrenoreceptor antagonists 1
• For patients with both hypertension and orthostatic hypotension, consider long-acting dihydropyridine calcium channel blockers or RAS inhibitors as first-line antihypertensive therapy 1
• Avoid beta-blockers in dysautonomic syndromes as they may enhance bradycardia 2

Monitoring and Follow-up

• Regular monitoring for adverse effects is essential, especially supine hypertension with pressor agents and electrolyte abnormalities with fludrocortisone 1
• Balance the benefits of increasing standing blood pressure against the risk of worsening supine hypertension 1
• For diabetic patients with orthostatic hypotension, assess for cardiovascular autonomic neuropathy 1

Treatment Algorithm

1. Start with comprehensive non-pharmacological measures for all patients 1, 2
2. If symptoms persist, add pharmacological therapy:
   • For most patients: Start with midodrine or fludrocortisone 4, 1
   • For neurogenic orthostatic hypotension: Consider droxidopa 1
3. For non-responders to monotherapy, consider combination therapy with midodrine and fludrocortisone 1
4. For refractory cases, add second-line agents (pyridostigmine, erythropoietin, desmopressin) 1, 2

Common Pitfalls and Caveats

• Avoid taking the last dose of midodrine after 6 PM to prevent supine hypertension during sleep 1
• Remember that the therapeutic goal is to minimize postural symptoms rather than to restore normotension 4, 1
• Midodrine can cause marked elevation of supine blood pressure (>200 mmHg systolic) and should be used cautiously 5
• Midodrine should be continued only for patients who report significant symptomatic improvement 5
• Caution is needed when using midodrine concomitantly with other agents that cause vasoconstriction, cardiac glycosides, psychopharmacologic agents, or beta blockers 5