From the Guidelines
The next step for a patient experiencing orthostatic hypotension while taking nortriptyline should be to reduce the medication dose, as this can help alleviate symptoms by minimizing the drug's alpha-1 adrenergic receptor blocking effects. This can be accomplished by decreasing the current dose by 25-50% while monitoring symptoms, as seen in patients with similar conditions 1. If the patient is on a higher dose (e.g., 75-150 mg daily), consider reducing to 50-75 mg daily. Alternatively, dividing the daily dose into smaller, more frequent administrations may help minimize blood pressure fluctuations. Orthostatic hypotension is a common anticholinergic side effect of tricyclic antidepressants like nortriptyline due to their alpha-1 adrenergic receptor blocking properties.
Additional measures include advising the patient to:
- rise slowly from sitting or lying positions
- maintain adequate hydration
- avoid alcohol
- consider adding salt to their diet if not contraindicated, as suggested by the 2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope 1
- use compression garments, which can improve orthostatic symptoms and blunt associated decreases in blood pressure, as recommended in the same guideline 1 If symptoms persist despite dose reduction, switching to an antidepressant with less orthostatic effects (such as an SSRI) may be necessary. Throughout this process, regular blood pressure monitoring in both sitting and standing positions is essential to evaluate the effectiveness of interventions. Midodrine and droxidopa are also approved by the FDA for the treatment of orthostatic hypotension, but should be considered if the above measures are not effective 1.
From the Research
Next Steps for Patient Experiencing Orthostatic Hypotension
The patient is taking nortriptyline for depression and is experiencing orthostatic hypotension. Considering the evidence, the next steps could be:
- Monitor the patient's blood pressure and adjust the nortriptyline dosage if necessary, as orthostatic hypotension can be a side effect of the medication 2
- Consider adding midodrine to the patient's treatment regimen, as it has been shown to be effective in increasing orthostatic blood pressure and ameliorating symptoms in patients with orthostatic hypotension 3, 4, 5
- However, it is essential to be aware of the potential side effects of midodrine, such as bradycardia, supine hypertension, and paresthesia, as well as the rare but reported side effect of nightmares 6
Key Considerations
- The patient's age and medical history should be taken into account when considering treatment options, as older adults may be more susceptible to the side effects of midodrine 6
- The dosage and frequency of midodrine administration should be carefully considered, as a 10-mg dose prescribed two to three times daily has been shown to be effective in increasing orthostatic blood pressure and ameliorating symptoms 3
- The patient's response to treatment should be closely monitored, and adjustments made as necessary to minimize side effects and optimize efficacy 4, 5