What is the treatment for orthostatic hypotension with fludrocortisone?

Treatment of Orthostatic Hypotension with Fludrocortisone

Fludrocortisone is a reasonable first-line or second-line pharmacological agent for orthostatic hypotension, starting at 0.05-0.1 mg daily and titrating to 0.1-0.3 mg daily, but only after implementing non-pharmacological measures and with careful monitoring for supine hypertension and hypokalemia. 1

Non-Pharmacological Measures Must Come First

Before initiating fludrocortisone, implement these foundational interventions:

• Increase fluid intake to 2-3 liters daily and salt consumption to 6-9 grams daily, unless contraindicated by heart failure 2, 1
• Elevate the head of the bed by 10 degrees during sleep to prevent nocturnal polyuria, maintain favorable fluid distribution, and reduce supine hypertension 2, 1
• Teach physical counter-maneuvers including leg crossing, squatting, stooping, and muscle tensing during symptomatic episodes 1
• Apply compression garments (waist-high stockings and abdominal binders) to reduce venous pooling 1
• Recommend smaller, more frequent meals to reduce post-prandial hypotension 1
• Encourage acute water ingestion of ≥480 mL for temporary relief, with peak effect at 30 minutes 1

Fludrocortisone Dosing Protocol

When non-pharmacological measures are insufficient:

• Start with 0.05-0.1 mg once daily in the morning 1
• Titrate individually to 0.1-0.3 mg daily based on response and tolerability 1
• An alternative loading approach uses 0.2 mg initially followed by 0.1 mg daily maintenance, with a maximum dose of 1.0 mg daily 1
• The drug works through sodium retention and direct vessel wall effects, not just volume expansion 1

Mechanism and Expected Effects

Fludrocortisone's therapeutic benefit comes from:

• Reducing the orthostatic decrease in cardiac output rather than simply expanding plasma volume 3
• The expanded fluid volume is allocated to the perivascular space more than the intravascular space 3
• Combined with head-up tilt sleeping, it can reduce the blood pressure drop after 1 minute of standing from -63/-40 mmHg to -21/-19 mmHg (systolic/diastolic) 4

Critical Monitoring Requirements

Monitor closely for these adverse effects:

• Supine hypertension is the most important limiting factor—check blood pressure in both supine and standing positions 1, 5
• Hypokalemia from mineralocorticoid effects requires periodic electrolyte monitoring 1, 5
• Peripheral edema and excessive weight gain indicate overdosage 5
• Heart failure exacerbation in susceptible patients 1

Absolute Contraindications

Do not use fludrocortisone in:

• Active heart failure or significant cardiac dysfunction 1
• Pre-existing severe supine hypertension 1
• Severe renal disease where sodium retention would be harmful 1

Combination Therapy for Non-Responders

If fludrocortisone monotherapy is insufficient:

• Add midodrine 2.5-5 mg three times daily (last dose before 6 PM to avoid nocturnal supine hypertension) 1
• The combination of fludrocortisone with midodrine is recommended for refractory cases 1
• Consider droxidopa as an alternative pressor agent 1

Treatment Goals and Realistic Expectations

The therapeutic objective is minimizing postural symptoms, not restoring normotension 1. This is critical because:

• It is impossible to normalize standing blood pressure without generating excessive supine hypertension 6
• The practical goal is improving standing blood pressure enough to undertake activities of daily living 6
• Balance the benefits of increasing standing pressure against the risk of worsening supine hypertension 1

Evidence Quality Caveat

The evidence supporting fludrocortisone is limited—only very low-certainty evidence from small, short-term trials exists 1, 7. A 2021 Cochrane review found very uncertain evidence about fludrocortisone's effects on blood pressure and orthostatic symptoms 7. However, guideline consensus from the American Diabetes Association, American Heart Association, and European Society of Cardiology supports its use as Class IIb (may be considered) 2, 1, reflecting decades of clinical experience despite limited high-quality trial data.

Common Pitfall to Avoid

Do not use fludrocortisone as monotherapy without concurrent non-pharmacological measures and head-up tilt sleeping—the combination is far more effective than either alone 4, 3. Studies show that head-up tilt sleeping combined with fludrocortisone reduces orthostatic blood pressure drops significantly more than either intervention alone 4.