How to manage orthostatic hypotension in a patient with hypertension?

Management of Orthostatic Hypotension in Hypertensive Patients

For hypertensive patients with orthostatic hypotension, switch blood pressure medications that worsen orthostatic symptoms to long-acting dihydropyridine calcium channel blockers or RAS inhibitors rather than simply reducing doses, while simultaneously implementing non-pharmacological measures as first-line treatment. 1, 2

Initial Assessment and Diagnosis

Before starting or intensifying any antihypertensive medication, test for orthostatic hypotension by having the patient sit or lie for 5 minutes, then measure blood pressure at 1 and 3 minutes after standing. 1, 2 A drop of ≥20 mmHg systolic or ≥10 mmHg diastolic defines orthostatic hypotension. 3

Critical first step: Review and discontinue all medications that worsen orthostatic hypotension, including commonly overlooked culprits like tamsulosin (alpha-1 blockers), trazodone, sildenafil, tizanidine, and carvedilol. 2, 4 This medication review takes priority over dose reduction of antihypertensives. 1, 2

Antihypertensive Medication Selection

Preferred Agents (Least Impact on Orthostatic BP)

• Long-acting dihydropyridine calcium channel blockers (e.g., amlodipine) are first-line choices, particularly for elderly patients aged ≥85 years or those with moderate-to-severe frailty. 1, 5

• RAS inhibitors (ACE inhibitors or ARBs) are equally preferred as first-line agents with minimal orthostatic effects. 1, 5

• SGLT2 inhibitors should be considered in patients with chronic kidney disease (eGFR >20 mL/min/1.73 m²) as they have modest BP-lowering properties without significant orthostatic effects. 1, 5

Agents to Avoid

• Beta-blockers should be avoided unless compelling indications exist (e.g., heart failure, post-MI). 1, 5

• Alpha-blockers (doxazosin, prazosin, terazosin) are strongly associated with orthostatic hypotension and should be discontinued. 2, 5

• Centrally-acting agents (clonidine, methyldopa) can worsen orthostatic symptoms. 5

Non-Pharmacological Management (Implement for ALL Patients)

Volume Expansion Strategies

• Increase fluid intake to 2-3 liters daily unless contraindicated by heart failure. 2

• Increase salt intake to 6-9 grams daily if not contraindicated. 2

• Acute water ingestion of ≥480 mL provides temporary relief with peak effect at 30 minutes. 2

Postural Modifications

• Elevate head of bed by 10 degrees during sleep to prevent nocturnal polyuria, maintain favorable fluid distribution, and reduce supine hypertension. 2

• Teach gradual staged movements when changing positions—avoid rapid standing. 2

• Implement physical counter-maneuvers during symptomatic episodes: leg crossing, squatting, stooping, and muscle tensing. 2

Dietary and Mechanical Interventions

• Recommend smaller, more frequent meals to reduce post-prandial hypotension. 2

• Use compression garments (waist-high stockings, abdominal binders) to reduce venous pooling. 2

• Encourage regular physical activity and exercise to prevent deconditioning, which worsens orthostatic intolerance. 2, 6

Pharmacological Treatment for Orthostatic Hypotension

Treatment goal: Minimize postural symptoms rather than restore normotension. 2 Balance the benefits of increasing standing BP against the risk of worsening supine hypertension. 2

First-Line Pharmacological Options (When Non-Pharmacological Measures Fail)

Midodrine (alpha-1 agonist):

• Start at 2.5-5 mg three times daily. 2
• Increases standing systolic BP by 15-30 mmHg for 2-3 hours. 2
• Critical caveat: Avoid last dose after 6 PM to prevent supine hypertension during sleep. 2
• FDA-approved for orthostatic hypotension. 2, 7

Fludrocortisone (mineralocorticoid):

• Start at 0.05-0.1 mg once daily, titrate to 0.1-0.3 mg daily. 2
• Acts through sodium retention and vessel wall effects. 2
• Monitor for: Supine hypertension (most important limiting factor), hypokalemia, peripheral edema, and heart failure exacerbation. 2
• Contraindications: Active heart failure, severe renal disease, pre-existing supine hypertension. 2

Droxidopa (norepinephrine precursor):

• FDA-approved for neurogenic orthostatic hypotension, particularly effective in Parkinson's disease, pure autonomic failure, and multiple system atrophy. 2, 8
• Important limitation: Effectiveness beyond 2 weeks is uncertain; patients should be evaluated periodically to determine ongoing benefit. 8
• In clinical trials, showed statistically significant 0.9 unit decrease in dizziness at Week 1 (P=0.028), but effect did not persist beyond Week 1. 8

Second-Line and Combination Therapy

• Pyridostigmine may be beneficial for refractory orthostatic hypotension, particularly in elderly patients, with fewer side effects than alternatives. 2

• Combination therapy with midodrine and fludrocortisone should be considered for non-responders to monotherapy. 2, 7

Special Considerations for Supine Hypertension

When orthostatic hypotension coexists with supine hypertension (common in this population):

• Prioritize non-pharmacological approaches over aggressive pharmacological treatment. 1

• Consider shorter-acting antihypertensives at bedtime to manage nocturnal hypertension without worsening morning orthostatic symptoms. 2

• Head elevation during sleep becomes even more critical. 2

Monitoring and Follow-Up

• Measure BP after 5 minutes lying/sitting, then at 1 and 3 minutes after standing to document orthostatic changes. 2

• Monitor for both symptomatic improvement AND development of supine hypertension. 2

• Check electrolytes periodically when using fludrocortisone due to potassium-wasting effects. 2

• Reassess within 1-2 weeks after medication changes. 2

• For patients on droxidopa, evaluate periodically as effectiveness beyond 2 weeks is uncertain. 8

Common Pitfalls to Avoid

• Do not simply reduce antihypertensive doses—this approach is inferior to switching to appropriate agents. 1, 2

• Do not overlook non-antihypertensive medications that worsen orthostatic hypotension (tamsulosin, trazodone, psychotropic drugs). 2, 4

• Do not treat to normotension—the goal is symptom relief, not BP normalization. 2

• Do not ignore supine hypertension—it can cause end-organ damage and limits treatment options. 2

• Do not use beta-blockers or alpha-blockers as antihypertensives in these patients unless absolutely necessary. 1, 5