What is the treatment for orthostatic hypotension?

Treatment of Orthostatic Hypotension

Begin with non-pharmacological interventions for all patients, and add midodrine or fludrocortisone when symptoms persist despite these measures, with the goal of minimizing postural symptoms rather than normalizing blood pressure. 1, 2

Initial Evaluation and Reversible Causes

Before initiating treatment, identify and eliminate exacerbating factors:

• Review and discontinue or switch medications that worsen orthostatic hypotension (diuretics, vasodilators, alpha-blockers, psychotropic drugs) rather than simply reducing doses 1
• Correct volume depletion and assess for endocrine disorders 1
• Evaluate renal and hepatic function before starting pharmacologic therapy 3
• Test for orthostatic hypotension by measuring blood pressure after 5 minutes supine/sitting, then at 1 and/or 3 minutes after standing 1

Non-Pharmacological Management (First-Line for All Patients)

Dietary Modifications

• Increase fluid intake to 2-3 liters daily 1
• Increase salt consumption to 6-9g daily (if not contraindicated by heart failure or other conditions) 1
• Consume smaller, more frequent meals to reduce post-prandial hypotension 1, 2
• Acute water ingestion of ≥480 mL provides temporary relief with peak effect at 30 minutes 1

Physical Maneuvers and Positioning

• Implement physical counter-maneuvers during symptom onset: leg crossing, muscle tensing, squatting, and stooping 1, 2
• Elevate the head of the bed by 10 degrees during sleep to prevent supine hypertension and nocturnal polyuria 1
• Practice gradual staged movements with postural changes 1, 2
• Use compression garments (thigh-high and abdominal compression) to reduce venous pooling 1, 2

Lifestyle Modifications

• Encourage physical activity and exercise to avoid deconditioning 1
• Avoid taking the last medication dose after 6 PM (when using pressor agents) to prevent supine hypertension during sleep 1

Pharmacological Management (When Non-Pharmacological Measures Fail)

First-Line Medications

Midodrine is the preferred initial pharmacologic agent:

• Dosing: Start at 2.5-5mg three times daily, can titrate up to 10mg three times daily 1, 2, 3
• Mechanism: Alpha-1 adrenergic agonist causing arteriolar and venous constriction 1
• Effect: Increases standing systolic BP by 15-30 mmHg for 2-3 hours 1
• FDA-approved for symptomatic orthostatic hypotension 3
• Key precaution: Avoid doses after 6 PM to prevent supine hypertension 1, 3
• Monitoring: Watch for supine hypertension (symptoms include cardiac awareness, pounding in ears, headache, blurred vision) 3

Fludrocortisone as an alternative or combination therapy:

• Dosing: Start at 0.05-0.1mg daily, titrate individually to 0.1-0.3mg daily 1, 2
• Mechanism: Mineralocorticoid that increases plasma volume through sodium retention and vessel wall effects 1
• Monitoring: Watch for hypokalemia, congestive heart failure, peripheral edema, and supine hypertension 1

Droxidopa as another first-line option:

• FDA-approved for neurogenic orthostatic hypotension 1, 2
• Particularly effective in Parkinson's disease, pure autonomic failure, and multiple system atrophy 1
• May reduce falls 1

Combination Therapy

• For non-responders to monotherapy, combine midodrine and fludrocortisone 1

Refractory Cases

Pyridostigmine for elderly patients refractory to other treatments:

• Favorable side effect profile compared to alternatives 1
• Supported by 2017 ACC/AHA/HRS guidelines for neurogenic orthostatic hypotension 1
• Common side effects include nausea, vomiting, abdominal cramping, sweating 1

Additional Options for Specific Situations

• Erythropoietin: Consider for patients with anemia and severe autonomic neuropathy 1
• Desmopressin acetate: May correct nocturnal polyuria and morning orthostatic hypotension 1

Special Populations

Patients with Concurrent Hypertension

• Use long-acting dihydropyridine calcium channel blockers or RAS inhibitors as first-line antihypertensive therapy 1
• Avoid RAS blockers in patients with isolated orthostatic hypotension due to vasodilatory effects 1
• Consider shorter-acting antihypertensives at bedtime to manage supine hypertension 1

Diabetic Patients

• Assess for cardiovascular autonomic neuropathy 1
• Consider alpha-lipoic acid for painful diabetic neuropathy with potential autonomic benefits 1
• Use midodrine cautiously in diabetic patients 3

Treatment Goals and Monitoring

The therapeutic goal is to minimize postural symptoms rather than restore normotension 1, 2. This is critical because:

• Attempting to normalize standing blood pressure will cause excessive supine hypertension 1
• Focus on improving standing time and ability to perform activities of daily living 1

Regular Monitoring Requirements

• Monitor for supine hypertension with all pressor agents 1
• Monitor electrolytes (especially potassium) with fludrocortisone 1
• Assess renal function before and during midodrine therapy 3
• Continue medication only if patients report significant symptomatic improvement 3

Critical Drug Interactions and Precautions

Avoid Concurrent Use With:

• Other vasoconstrictors (phenylephrine, pseudoephedrine, ephedrine, dihydroergotamine) increase hypertension risk 3
• MAO inhibitors or linezolid with midodrine 3
• Alpha-adrenergic blocking agents (prazosin, terazosin, doxazosin) antagonize midodrine effects 3

Use Cautiously With:

• Cardiac glycosides (may precipitate bradycardia, AV block, or arrhythmia) 3
• Beta blockers or other agents that reduce heart rate 3
• Patients with urinary retention (midodrine acts on bladder neck alpha-receptors) 3
• Patients with visual problems taking fludrocortisone (increased intraocular pressure risk) 3

Common Pitfalls to Avoid

• Do not simply reduce doses of causative medications—switch to alternatives 1
• Do not allow patients to take midodrine if they will be supine for extended periods 3
• Do not ignore supine hypertension monitoring, as this is the most common serious adverse effect 1, 3
• Do not continue pharmacologic therapy without documented symptomatic improvement 3