How to manage orthostatic (postural) hypotension?

Management of Orthostatic Hypotension

Begin with non-pharmacological interventions in all patients, and add fludrocortisone (0.05-0.1 mg daily) or midodrine (2.5-5 mg three times daily) when lifestyle measures fail to adequately control symptoms, with the goal of minimizing postural symptoms rather than restoring normotension. 1

Initial Assessment and Reversible Causes

Immediately review and discontinue or switch all medications that worsen orthostatic hypotension - do not simply reduce doses, as switching to alternative therapy is more effective. 1 The most common culprits are diuretics, vasodilators, ACE inhibitors, calcium channel blockers, alpha-blockers, and psychotropic medications. 1 Drug-induced autonomic failure is the single most frequent cause of orthostatic hypotension. 1

Evaluate for volume depletion, anemia, endocrine disorders (particularly adrenal insufficiency), and cardiovascular autonomic neuropathy, especially in diabetic patients. 1

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

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

Volume Expansion Strategies

• Increase fluid intake to 2-3 liters daily unless contraindicated by heart failure 1
• Increase salt consumption to 6-9 grams daily (approximately 1-2 teaspoons of table salt) if not contraindicated 1
• Acute water bolus therapy: drinking ≥480 mL of water provides temporary relief with peak effect at 30 minutes after consumption 1

Physical Counter-Maneuvers

• Teach leg crossing, squatting, stooping, and muscle tensing during symptomatic episodes - these are particularly effective in patients under 60 years with prodromal symptoms 1
• Implement leg muscle pumping and contractions when standing 2
• Bending forward can acutely improve symptoms 2

Compression Garments

• Use waist-high compression stockings (30-40 mmHg) and abdominal binders to reduce venous pooling 1
• Abdominal compression is more effective than lower limb compression alone 3, 2

Postural and Dietary Modifications

• Elevate the head of the bed by 10 degrees during sleep to prevent nocturnal polyuria, maintain favorable fluid distribution, and ameliorate nocturnal hypertension 1
• Eat smaller, more frequent meals to reduce post-prandial hypotension 1
• Reduce carbohydrate content in meals 3
• Teach gradual staged movements with postural changes - avoid rapid standing 1

Exercise and Physical Activity

• Encourage regular physical activity and exercise to avoid deconditioning, which worsens orthostatic intolerance 1
• Swimming is particularly beneficial as it involves judicious exercise of leg and abdominal muscles 3

Pharmacological Management (When Non-Pharmacological Measures Fail)

First-Line Pharmacological Options

Midodrine has the strongest evidence base among pressor agents with three randomized placebo-controlled trials demonstrating efficacy. 1

Midodrine (Preferred First-Line Agent)

• Start at 2.5-5 mg three times daily 1, 4
• Increases standing systolic BP by 15-30 mmHg for 2-3 hours 1, 4
• Take the last dose at least 3-4 hours before bedtime (no doses after 6 PM) to prevent supine hypertension during sleep 1, 4
• FDA-approved specifically for symptomatic orthostatic hypotension 4
• Works as an alpha-1 agonist causing arteriolar and venous constriction without direct cardiac or CNS effects 4
• Use with caution in older males due to potential urinary retention (acts on alpha-adrenergic receptors of bladder neck) 4

Fludrocortisone (Alternative or Combination First-Line)

• Start at 0.05-0.1 mg once daily, titrate to 0.1-0.3 mg daily (maximum 1.0 mg daily) 1
• Works through sodium retention and vessel wall effects 1
• Monitor for supine hypertension (most important limiting factor), hypokalemia, peripheral edema, and heart failure exacerbation 1
• Contraindicated in active heart failure, severe renal disease, and pre-existing supine hypertension 1
• Check electrolytes periodically due to mineralocorticoid effects causing potassium wasting 1

Droxidopa

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

Combination Therapy

For patients not responding to monotherapy, combine midodrine with fludrocortisone - this approach addresses both vascular tone and volume expansion. 1

Refractory Cases

For patients refractory to standard first-line agents:

• Pyridostigmine may be beneficial with a favorable side effect profile compared to alternatives, though evidence is limited to refractory neurogenic orthostatic hypotension 1
• Desmopressin for patients with nocturnal polyuria 3
• Octreotide for post-prandial hypotension 3
• Erythropoietin for patients with anemia and severe autonomic neuropathy 1

Treatment Goals and Monitoring

The therapeutic objective is minimizing postural symptoms and improving functional capacity, NOT restoring normotension. 1 Attempting to normalize blood pressure will inevitably cause supine hypertension with end-organ damage risk.

Blood Pressure Monitoring Protocol

• Measure BP after 5 minutes of lying/sitting, then at 1 and 3 minutes after standing to document orthostatic changes 1
• Monitor closely for supine hypertension development - this is the most important adverse effect to avoid 1, 4
• Balance the benefits of increasing standing BP against the risk of worsening supine hypertension 1

Follow-Up Schedule

• Reassess within 1-2 weeks after medication changes 1
• Continue midodrine only if patients report significant symptomatic improvement 4

Critical Pitfalls to Avoid

• Never simply reduce the dose of offending antihypertensive medications - switch to alternative therapy instead 1
• Avoid RAS blockers in patients with orthostatic hypotension due to vasodilatory effects 1
• Do not allow patients to become fully supine if supine hypertension develops - sleeping with head elevated controls this 4
• Avoid combining midodrine with other vasoconstrictors (phenylephrine, pseudoephedrine, ephedrine) without careful BP monitoring 4
• Use caution when combining midodrine with cardiac glycosides or beta-blockers as these may precipitate bradycardia or AV block 4
• Warn patients about over-the-counter cold remedies and diet aids that can potentiate pressor effects 4

Special Populations

Patients with Concurrent Hypertension and Orthostatic Hypotension

Consider long-acting dihydropyridine calcium channel blockers or RAS inhibitors as first-line antihypertensive therapy in this challenging population. 1 Test for orthostatic hypotension before starting or intensifying any BP-lowering medication, especially in elderly patients. 1

Diabetic Patients

Assess for cardiovascular autonomic neuropathy and consider alpha-lipoic acid for painful diabetic neuropathy, which may have beneficial effects on autonomic function. 1