How to manage orthostatic hypotension?

Management of Orthostatic Hypotension

Diagnosis Confirmation

Your patient has confirmed orthostatic hypotension with a drop of 22 mmHg systolic (103→81) and 13 mmHg diastolic (67→54) at 3 minutes standing, meeting diagnostic criteria. 1

• Measure blood pressure after 5 minutes lying/sitting, then at 1 and 3 minutes after standing to document orthostatic changes 1
• Orthostatic hypotension is defined as a decrease of ≥20 mmHg systolic or ≥10 mmHg diastolic within 3 minutes of standing 2, 3
• The heart rate increase from 85→118 bpm (39% increase) suggests a compensatory response, which helps distinguish nonneurogenic from neurogenic causes 2

Initial Management Steps

1. Identify and Address Reversible Causes

Immediately review and discontinue or switch any blood pressure-lowering medications that worsen orthostatic hypotension rather than simply reducing doses. 1

• Diuretics and vasodilators are the most common medication culprits 4
• ACE inhibitors, calcium channel blockers, and RAS blockers should be switched to alternative therapy if they worsen orthostatic hypotension 1
• Avoid medications that exacerbate orthostatic hypotension including psychotropic drugs, α-adrenoreceptor antagonists, and alcohol 1
• Assess for volume depletion, endocrine disorders (especially diabetes), and neurological conditions 1

2. Non-Pharmacological Interventions (First-Line for All Patients)

Implement these evidence-based non-pharmacological measures immediately, as they form the foundation of treatment: 1, 4

Fluid and Salt Management:

• Increase fluid intake to 2-3 liters daily unless contraindicated by heart failure 1, 4
• Increase salt intake to 6-9g daily (up to 10g) if not contraindicated 1, 4
• Acute water ingestion of ≥480 mL provides temporary relief with peak effect at 30 minutes 1

Physical Countermeasures:

• Teach leg crossing, squatting, stooping, and muscle tensing during symptomatic episodes 1, 4
• These maneuvers can be implemented immediately when warning symptoms occur 4
• Encourage gradual staged movements with postural changes 1

Compression Garments:

• Use waist-high compression stockings and abdominal binders to reduce venous pooling 1, 4
• Thigh-high and abdominal compression are specifically recommended 1

Lifestyle Modifications:

• Elevate the head of bed by 10 degrees during sleep to prevent nocturnal polyuria, maintain favorable fluid distribution, and ameliorate nocturnal hypertension 1, 4
• Eat smaller, more frequent meals to reduce post-prandial hypotension 1
• Encourage physical activity and exercise to avoid deconditioning 1

Pharmacological Management

When to Initiate Medications

Consider pharmacological treatment when non-pharmacological measures fail to adequately control symptoms, with the therapeutic goal of minimizing postural symptoms rather than restoring normotension. 1

First-Line Pharmacological Options

Midodrine (Preferred First-Line Agent):

• Start with 2.5-5 mg three times daily, can titrate up to 10 mg three times daily 1, 4, 5
• Midodrine is an alpha-1 agonist that increases standing systolic BP by 15-30 mmHg for 2-3 hours 1, 5
• Critical timing: Avoid taking the last dose after 6 PM to prevent supine hypertension during sleep 1, 5
• Peak effect occurs 1-2 hours after dosing with duration of 2-3 hours 5
• FDA-approved specifically for symptomatic orthostatic hypotension 5
• Monitor for supine hypertension (BP >200 mmHg systolic can occur) 5

Fludrocortisone (Alternative First-Line Agent):

• Start with 0.05-0.1 mg once daily, titrate individually to 0.1-0.3 mg daily (maximum 1.0 mg daily) 1, 4
• Acts through sodium retention and vessel wall effects, expanding plasma volume 1, 4
• Contraindicated in active heart failure, significant cardiac dysfunction, severe renal disease, and pre-existing supine hypertension 1
• Monitor for supine hypertension (most important limiting factor), hypokalemia, peripheral edema, and congestive heart failure 1
• Check electrolytes periodically due to mineralocorticoid effects causing potassium wasting 1
• Evidence quality is limited with only very low-certainty evidence from small, short-term trials 1

Droxidopa (Alternative First-Line Agent):

• FDA-approved for neurogenic orthostatic hypotension 1, 4
• Particularly effective in Parkinson's disease, pure autonomic failure, and multiple system atrophy 1
• May reduce falls in neurogenic orthostatic hypotension 1

Second-Line and Adjunctive Agents

For Refractory Cases:

• Pyridostigmine may be beneficial for refractory orthostatic hypotension in elderly patients with fewer side effects than alternatives 1, 4
• Consider combination therapy with midodrine and fludrocortisone for non-responders to monotherapy 1
• Octreotide may be considered for post-prandial hypotension 4
• Desmopressin may correct nocturnal polyuria and morning orthostatic hypotension 1, 4
• Erythropoietin can be considered for patients with anemia and severe autonomic neuropathy 1, 4

Treatment Goals and Monitoring

The therapeutic objective is minimizing postural symptoms and improving functional capacity, NOT restoring normotension. 1, 3, 6

• Balance increasing standing blood pressure against the risk of worsening supine hypertension 1
• Monitor blood pressure in supine/sitting and standing positions at 1 and 3 minutes to document both symptomatic improvement and development of supine hypertension 1
• Reassess within 1-2 weeks after medication changes 1
• Continue treatment only for patients who report significant symptomatic improvement 5

Critical Pitfalls to Avoid

Supine Hypertension Management:

• Supine hypertension commonly coexists with orthostatic hypotension and can cause end-organ damage 1, 7
• Prevent patients from becoming fully supine by sleeping with head of bed elevated 5
• Patients should avoid taking doses if they will be supine for any length of time 5
• Consider shorter-acting antihypertensives at bedtime if supine hypertension develops 1

Medication Interactions:

• Avoid MAO inhibitors or linezolid with midodrine 5
• Cardiac glycosides may enhance bradycardia, AV block, or arrhythmia when combined with midodrine 5
• Alpha-adrenergic blocking agents (prazosin, terazosin, doxazosin) antagonize midodrine's effects 5
• Over-the-counter cold remedies and diet aids can potentiate pressor effects 5

Special Populations:

• In patients with renal impairment, start midodrine at 2.5 mg due to renal elimination of active metabolite 5
• Diabetic patients should be routinely assessed for orthostatic hypotension, particularly after age 50 7
• Beta-blockers may be detrimental in dysautonomic syndromes 4

Important Evidence Context

Intensive blood pressure control does NOT worsen orthostatic hypotension. Data from SPRINT and meta-analyses show that intensive BP lowering actually reduces the risk of orthostatic hypotension, possibly due to improvement in baroreflex function and reduction in left ventricular hypertrophy and arterial stiffness. 8 Asymptomatic orthostatic hypotension during hypertension treatment should not trigger automatic down-titration of therapy. 8