What are the treatment options for orthostatic hypotension with dizziness?

Treatment of Orthostatic Hypotension with Dizziness

Begin with non-pharmacological interventions first, and if symptoms persist despite these measures, initiate fludrocortisone 0.05-0.1 mg daily as first-line pharmacological therapy, with midodrine 2.5-5 mg three times daily as second-line if needed. 1

Initial Assessment and Reversible Causes

Before initiating treatment, confirm the diagnosis by measuring blood pressure after 5 minutes of sitting/lying, then at 1 and/or 3 minutes after standing 1. The most critical first step is identifying and eliminating reversible causes, particularly medications 1:

• Drug-induced autonomic failure is the most frequent cause - diuretics and vasodilators are the primary culprits 1
• Alpha-1 blockers (doxazosin, prazosin, terazosin) are strongly associated with orthostatic hypotension, especially in older adults 2
• Other high-risk medications include centrally-acting drugs (clonidine, methyldopa), vasodilators (hydralazine, minoxidil), and psychotropic medications 2
• Switch problematic BP-lowering medications to alternatives rather than simply reducing the dose - if antihypertensives are needed, use long-acting dihydropyridine calcium channel blockers or RAS inhibitors as they have minimal impact on orthostatic blood pressure 1, 2

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

These interventions should be implemented before or alongside any pharmacological therapy 1:

Fluid and Salt Management:

• Increase fluid intake to 2-3 liters daily (unless contraindicated by heart failure) 1
• Increase salt intake to 6-9 grams daily (if not contraindicated) 1
• 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
• These maneuvers can be implemented immediately when symptoms occur 1

Positional Strategies:

• Elevate the head of bed by 10 degrees during sleep to prevent nocturnal polyuria and supine hypertension 1
• Practice gradual staged movements with postural changes 1

Compression Garments:

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

Dietary Modifications:

• Eat smaller, more frequent meals to reduce post-prandial hypotension 1

Exercise:

• Encourage physical activity and exercise to avoid deconditioning, which worsens orthostatic intolerance 1

Pharmacological Management (When Non-Pharmacological Measures Fail)

The therapeutic goal is minimizing postural symptoms rather than restoring normotension 1. Treatment should only be continued if patients report significant symptomatic improvement 3.

First-Line: Fludrocortisone

• Start with 0.05-0.1 mg once daily, titrating individually to 0.1-0.3 mg daily 1
• Acts through sodium retention and vessel wall effects 1
• Alternative dosing: 0.2 mg loading dose followed by 0.1 mg daily maintenance (maximum 1.0 mg daily) 1

Critical Monitoring for Fludrocortisone:

• Supine hypertension is the most important limiting factor - monitor blood pressure in supine position regularly 1
• Check electrolytes periodically due to potassium wasting from mineralocorticoid effects 1
• Monitor for peripheral edema and signs of congestive heart failure 1

Contraindications:

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

Second-Line: Midodrine

If fludrocortisone is insufficient or contraindicated, add midodrine 1:

• Start with 2.5-5 mg three times daily 1, 3
• Midodrine is an alpha-1 agonist that increases standing systolic BP by 15-30 mmHg for 2-3 hours 1, 3
• Avoid taking the last dose after 6 PM to prevent supine hypertension during sleep 1, 3
• FDA-approved specifically for symptomatic orthostatic hypotension 3

Key Precautions for Midodrine:

• Can cause marked elevation of supine blood pressure (>200 mmHg systolic) 3
• Should only be used in patients whose lives are considerably impaired despite standard clinical care 3
• Use with caution in patients with urinary retention, as it acts on alpha-adrenergic receptors of the bladder neck 3
• Start with 2.5 mg in patients with renal impairment 3
• May cause slight slowing of heart rate due to vagal reflex 3

Combination Therapy

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

Third-Line: Droxidopa

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

Alternative Agent: Pyridostigmine

• Beneficial for refractory orthostatic hypotension in elderly patients who have not responded to other treatments 1
• Favorable side effect profile compared to fludrocortisone - does not cause fluid retention or supine hypertension 1, 2
• Common side effects include nausea, vomiting, abdominal cramping, sweating, salivation, and urinary incontinence 1

Critical Pitfalls to Avoid

• Never simply reduce the dose of problematic antihypertensives - switch to alternative agents instead 1
• Do not pursue normotension as a goal - this will inevitably cause excessive supine hypertension 1, 4
• Avoid RAS blockers in patients with orthostatic hypotension due to vasodilatory effects 1
• Monitor for supine hypertension when using pressor agents - this is the primary treatment-limiting adverse effect 1
• Reassess within 1-2 weeks after medication changes to evaluate response and adjust therapy 1
• Balance the risk of falls and injury from postural hypotension against cardiovascular protection when managing concurrent hypertension 1

Special Populations

Elderly/Frail Patients:

• Test for orthostatic hypotension before starting or intensifying any BP-lowering medication 1, 2
• If antihypertensives are needed, prefer long-acting dihydropyridine calcium channel blockers or RAS inhibitors 2

Diabetic Patients:

• Assess for cardiovascular autonomic neuropathy 1
• Use midodrine with caution, especially if also taking fludrocortisone, due to increased risk of intraocular pressure elevation and glaucoma 3

Patients on Hemodialysis:

• Midodrine is removed by dialysis 3