What are the treatment options for orthostatic (postural) hypotension?

From the Guidelines

Treatment for orthostatic hypotension should prioritize non-pharmacological approaches, including increasing fluid intake to 2-3 liters daily and salt consumption to 8-10 grams per day, unless contraindicated, as well as physical countermeasures like wearing compression stockings and regular moderate exercise, as these methods have been shown to minimize symptoms and improve vascular tone 1.

Non-Pharmacological Approaches

• Increasing fluid intake to 2-3 liters daily and salt consumption to 8-10 grams per day, unless contraindicated by other conditions, can help expand blood volume and reduce symptoms of orthostatic hypotension 1.
• Physical countermeasures such as:
  • Standing up slowly
  • Avoiding prolonged standing
  • Elevating the head of the bed by 4-6 inches
  • Wearing compression stockings, particularly those that are at least thigh high and include the abdomen, as these have been shown to improve orthostatic symptoms and blunt associated decreases in blood pressure 1.
• Regular moderate exercise, particularly swimming or recumbent biking, can improve vascular tone and reduce symptoms of orthostatic hypotension.

Pharmacological Approaches

• Midodrine (ProAmatine) 2.5-10 mg three times daily is a recommended medication option, as it is an alpha-1 agonist that increases peripheral vascular resistance, but should be taken during waking hours only and not within 4 hours of bedtime to avoid supine hypertension 1.
• Droxidopa (Northera) 100-600 mg three times daily can be effective for neurogenic orthostatic hypotension, as it improves symptoms of neurogenic OH due to Parkinson disease, pure autonomic failure, and multiple system atrophy 1.
• Fludrocortisone (Florinef) 0.1-0.3 mg daily may be beneficial in patients with syncope due to neurogenic OH, as it increases plasma volume and improves symptoms of OH, but its use may be limited by supine hypertension 1.
• Pyridostigmine 30-60 mg three times daily may benefit patients with autonomic failure, as it improves orthostatic tolerance through increases in peripheral vascular resistance and blood pressure 1.

Individualized Treatment

Treatment for orthostatic hypotension should be individualized based on symptom severity, underlying causes, and comorbidities, taking into account the potential benefits and risks of each treatment option, as well as the need to minimize postural symptoms rather than restoring normotension 1.

From the FDA Drug Label

Midodrine hydrochloride tablets are indicated for the treatment of symptomatic orthostatic hypotension (OH) Because midodrine hydrochloride tablets can cause marked elevation of supine blood pressure (BP>200 mmHg systolic), it should be used in patients whose lives are considerably impaired despite standard clinical care, including non-pharmacologic treatment (such as support stockings), fluid expansion, and lifestyle alterations

Treatment for Orthostatic Hypotension: Midodrine hydrochloride tablets are indicated for the treatment of symptomatic orthostatic hypotension (OH). The treatment should be used in patients whose lives are considerably impaired despite standard clinical care.

• Key Considerations:
  • Midodrine can cause marked elevation of supine blood pressure
  • Should be used in patients with significant impairment despite standard clinical care
  • Non-pharmacologic treatments, such as support stockings and lifestyle alterations, should be considered before initiating midodrine therapy 2

From the Research

Treatment Options for Orthostatic Hypotension

• Non-pharmacologic measures are often the first line of treatment, aiming to optimize blood volume, decrease postural venous pooling, and reduce heat and post-prandial induced vasodilation 3, 4, 5, 6, 7
• These measures include:
  • Dietary modifications, such as increasing fluid and sodium intake 4, 5, 7
  • Compression garments, such as stockings 4, 5, 7
  • Physical maneuvers, like leg crossing, leg muscle pumping/contractions, and bending forward 7
  • Avoiding environments that exacerbate symptoms, like heat 3, 5
  • Sleeping with the head of the bed elevated 4, 6, 7
• Pharmacologic treatment may be necessary for more severe symptoms, with medications like:
  • Midodrine 4, 5, 6
  • Droxidopa 5, 6
  • Fludrocortisone, although its use is limited due to potential adverse effects 4, 6
• The treatment approach may vary depending on the underlying cause of orthostatic hypotension, with neurogenic and non-neurogenic orthostatic hypotension requiring different management strategies 5, 6

Management Goals

• The primary goal of treatment is to reduce symptoms and improve quality of life, rather than normalizing blood pressure 5, 6
• Treatment should be individualized, taking into account the patient's abilities and impairments, as well as the underlying cause of orthostatic hypotension 5, 6, 7

Effectiveness of Non-Pharmacological Interventions

• A systematic review found mixed results for the effectiveness of non-pharmacological interventions in treating orthostatic hypotension in elderly people and those with neurological conditions 7
• Some non-pharmacological interventions, such as physical maneuvers and abdominal compression, may be effective in improving orthostatic hypotension, while others, like resistance exercise and electrical stimulation, showed no significant effect 7