How is orthostatic hypotension managed?

Management of Orthostatic Hypotension

Begin with non-pharmacological interventions for all patients, and add midodrine as first-line pharmacological therapy when symptoms persist despite conservative measures, reserving fludrocortisone for combination therapy or when midodrine is insufficient. 1

Initial Assessment and Reversible Causes

• Measure blood pressure after 5 minutes of lying/sitting, then at 1 and 3 minutes after standing to confirm the diagnosis (≥20 mmHg systolic or ≥10 mmHg diastolic drop). 1
• Immediately discontinue or switch any medications worsening orthostatic hypotension rather than simply reducing doses - this is the most critical first step. 1
• The most common culprits are diuretics (especially thiazides), alpha-1 blockers (doxazosin, tamsulosin), centrally-acting agents (clonidine), and vasodilators. 1, 2
• Assess for volume depletion, anemia, and endocrine disorders (adrenal insufficiency, hypothyroidism) as reversible causes. 1

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

Fluid and salt expansion:

• Increase fluid intake to 2-3 liters daily unless contraindicated by heart failure. 1
• Increase salt intake to 6-10 grams daily if not contraindicated. 1
• Acute water ingestion of ≥480 mL provides temporary relief with peak effect at 30 minutes - useful before standing activities. 1

Physical countermeasures (particularly effective in patients <60 years with prodromal symptoms):

• Teach leg crossing, squatting, stooping, and muscle tensing during symptomatic episodes. 1
• These maneuvers can acutely raise blood pressure by 20-30 mmHg. 1

Compression therapy:

• Use waist-high compression stockings (30-40 mmHg) and abdominal binders to reduce venous pooling. 1
• Thigh-high stockings alone are less effective than abdominal compression. 1

Postural modifications:

• Elevate the head of the bed by 10 degrees during sleep to prevent nocturnal polyuria, maintain fluid distribution, and reduce supine hypertension. 1
• Teach gradual staged movements with postural changes - avoid rapid standing. 1

Dietary adjustments:

• Eat smaller, more frequent meals to reduce post-prandial hypotension. 3, 1
• Avoid large carbohydrate-heavy meals. 1

Exercise:

• Encourage physical activity and exercise to prevent deconditioning, which exacerbates orthostatic intolerance. 3, 1

Pharmacological Management (When Non-Pharmacological Measures Fail)

The therapeutic goal is minimizing postural symptoms and improving functional capacity, NOT restoring normotension. 1

First-Line: Midodrine

• Midodrine has the strongest evidence base among pressor agents with three randomized placebo-controlled trials demonstrating efficacy. 1
• Start at 2.5-5 mg three times daily. 1, 4
• Increases standing systolic BP by 15-30 mmHg for 2-3 hours. 3, 4
• Critical: Give the last dose at least 3-4 hours before bedtime (no later than 6 PM) to prevent supine hypertension during sleep. 3, 1, 4
• FDA-approved specifically for symptomatic orthostatic hypotension. 4
• Monitor for supine hypertension (BP >200 mmHg systolic can occur). 4

Second-Line: Fludrocortisone

• Start at 0.05-0.1 mg once daily, titrate to 0.1-0.3 mg daily based on response. 3, 1
• Acts through sodium retention and vessel wall effects to expand plasma volume. 3, 1
• Add to midodrine for combination therapy if monotherapy provides insufficient symptom control. 1
• Contraindications: Active heart failure, severe renal disease, pre-existing supine hypertension. 1
• Monitor for hypokalemia, peripheral edema, and supine hypertension. 3, 1
• Evidence quality is limited with only very low-certainty evidence from small trials. 1

Alternative: Droxidopa

• FDA-approved for neurogenic orthostatic hypotension. 3, 1
• Particularly effective for Parkinson's disease, pure autonomic failure, and multiple system atrophy. 1
• May reduce falls in these populations. 1

Refractory Cases: Pyridostigmine

• Consider for neurogenic orthostatic hypotension refractory to other treatments. 1
• Favorable side effect profile compared to fludrocortisone - does not cause fluid retention or supine hypertension. 1
• Common side effects include nausea, abdominal cramping, and increased salivation. 1

Critical Monitoring Requirements

• Measure blood pressure supine and standing at each follow-up to assess for supine hypertension. 1
• Supine hypertension is the most important limiting factor in treatment and can cause end-organ damage. 1
• Monitor electrolytes periodically when using fludrocortisone due to potassium wasting. 1
• Reassess within 1-2 weeks after medication changes. 1

Special Populations

Diabetic patients with cardiac autonomic neuropathy:

• Orthostatic hypotension in diabetes is often associated with cardiac autonomic neuropathy and carries increased mortality risk. 3
• The same treatment algorithm applies, with particular attention to glycemic control optimization. 3

Patients requiring continued antihypertensive therapy:

• Prefer long-acting dihydropyridine calcium channel blockers or RAS inhibitors (ACE inhibitors/ARBs) as they have minimal impact on orthostatic blood pressure. 1, 2
• Avoid beta-blockers unless compelling indications exist. 2

Common Pitfalls to Avoid

• Do not simply reduce doses of offending medications - switch to alternatives entirely. 1
• Do not allow midodrine dosing after 6 PM - this is the most common cause of treatment-related supine hypertension. 1
• Do not aim for normal blood pressure - the goal is symptom relief and improved standing time, not normotension. 3, 1
• Do not overlook medication review - drug-induced autonomic failure is the most frequent cause of orthostatic hypotension. 1
• Do not start pharmacological therapy without implementing non-pharmacological measures first. 1