What is the treatment for orthostatic hypotension?

Treatment of Orthostatic Hypotension

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

Initial Evaluation and Reversible Causes

• Identify and eliminate exacerbating medications first—diuretics and vasodilators are the most common culprits causing drug-induced orthostatic hypotension 1
• Switch (not just reduce) blood pressure medications that worsen orthostatic hypotension to alternative agents; avoid RAS blockers due to vasodilatory effects 1
• Correct volume depletion and assess for endocrine disorders, cardiovascular causes, and neurogenic etiologies 1, 2
• Discontinue alcohol, which causes orthostatic intolerance through central nervous system effects and volume depletion 1

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

Fluid and Salt Expansion:

• Increase fluid intake to 2-3 liters daily (unless contraindicated by heart failure) 1
• Increase salt consumption to 6-9 grams daily (if not contraindicated) 1, 2
• Acute water ingestion of ≥480 mL provides temporary relief with peak effect at 30 minutes 1

Physical Countermaneuvers:

• Teach leg crossing, squatting, stooping, and muscle tensing during symptomatic episodes 1, 2
• Implement gradual staged movements with postural changes 1, 2

Compression Garments:

• Use waist-high compression stockings and abdominal binders to reduce venous pooling 1, 2

Lifestyle Modifications:

• Elevate head of bed by 10 degrees during sleep to prevent nocturnal polyuria, maintain fluid distribution, and reduce supine hypertension 1
• Eat smaller, more frequent meals to reduce post-prandial hypotension 1, 2
• Encourage physical activity and exercise to avoid deconditioning 1

Pharmacological Management (When Non-Pharmacological Measures Fail)

First-Line Agents:

Midodrine (Alpha-1 Agonist):

• Start at 2.5-5 mg three times daily, can titrate up to 10 mg three times daily 1, 2, 3
• Increases standing systolic BP by 15-30 mmHg for 2-3 hours 1
• Critical timing: Avoid last dose after 6 PM to prevent supine hypertension during sleep 1, 3
• FDA-approved for symptomatic orthostatic hypotension 3
• Monitor for supine hypertension (BP >200 mmHg systolic possible); patients should report cardiac awareness, pounding in ears, headache, or blurred vision immediately 3
• Use cautiously with cardiac glycosides (risk of bradycardia), other vasoconstrictors, and in patients with urinary retention 3

Fludrocortisone (Mineralocorticoid):

• Start at 0.05-0.1 mg daily, titrate individually to 0.1-0.3 mg daily (maximum 1.0 mg daily) 1, 2
• Works through sodium retention and vessel wall effects, increasing plasma volume 1
• Contraindicated in active heart failure, significant cardiac dysfunction, severe renal disease, and pre-existing supine hypertension 1
• Monitor for hypokalemia, supine hypertension, congestive heart failure, and peripheral edema 1
• Evidence quality is limited (very low-certainty from small, short-term trials) 1

Droxidopa:

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

Second-Line and Combination Therapy:

• For non-responders to monotherapy, consider combination of midodrine and fludrocortisone 1
• Pyridostigmine for refractory cases: Beneficial in elderly patients refractory to other treatments with fewer side effects than alternatives; start low and titrate based on response 1
• Erythropoietin for patients with anemia and severe autonomic neuropathy 1
• Desmopressin acetate may correct nocturnal polyuria and morning orthostatic hypotension 1

Treatment Goals and Monitoring

Primary Goal:

• Minimize postural symptoms and improve standing time to perform activities of daily living—NOT to restore normotension 1, 2
• Balance increasing standing BP against risk of worsening supine hypertension 1

Monitoring Protocol:

• Measure BP after 5 minutes lying/sitting, then at 1 and 3 minutes after standing 1, 2
• Monitor for supine hypertension regularly (most important limiting factor with pressor agents) 1
• Check electrolytes periodically with fludrocortisone due to potassium wasting 1
• Assess renal and hepatic function before initiating therapy and periodically thereafter 3
• Reassess within 1-2 weeks after medication changes 1

Special Populations

Diabetic Patients:

• Assess for cardiovascular autonomic neuropathy 1
• Consider α-lipoic acid for painful diabetic neuropathy (potentially beneficial for autonomic function) 1
• Use midodrine cautiously in diabetic patients 3

Patients with Concurrent Hypertension:

• Consider long-acting dihydropyridine calcium channel blockers or RAS inhibitors as first-line for hypertension management 1
• Shorter-acting antihypertensives at bedtime may help manage supine hypertension 1

Critical Pitfalls to Avoid

• Do not simply reduce doses of offending medications—switch to alternatives 1
• Avoid over-the-counter cold remedies and diet aids containing sympathomimetics, which can potentiate pressor effects 3
• Do not use MAO inhibitors or linezolid with midodrine 3
• Avoid alpha-adrenergic blocking agents (prazosin, terazosin, doxazosin), which antagonize midodrine effects 3
• Do not allow patients to take midodrine if they will be supine for extended periods 3
• Continue midodrine only if patients report significant symptomatic improvement 3