What is the treatment for orthostatic hypotension?

Treatment of Orthostatic Hypotension

Begin with non-pharmacological interventions for all patients, and add pharmacological therapy only when symptoms persist despite these measures, with midodrine as the first-line medication. 1

Step 1: Identify and Eliminate Reversible Causes

• Discontinue or switch medications that worsen orthostatic hypotension rather than simply reducing doses 1, 2
• The most common culprits are diuretics (especially thiazides), alpha-1 blockers (doxazosin, prazosin, terazosin), vasodilators, and centrally-acting antihypertensives 1, 2
• For patients requiring continued antihypertensive therapy, switch to long-acting dihydropyridine calcium channel blockers or RAS inhibitors (ACE inhibitors/ARBs), which have minimal impact on orthostatic blood pressure 2
• Evaluate for volume depletion, anemia, and endocrine disorders 1

Step 2: Implement Non-Pharmacological Interventions (All Patients)

Fluid and Salt Management

• Increase fluid intake to 2-3 liters daily 1
• Increase salt intake to 6-9 grams daily (unless contraindicated by heart failure) 1
• Acute water ingestion of ≥480 mL provides temporary relief with peak effect at 30 minutes 1

Physical Maneuvers and Positioning

• Teach leg crossing, squatting, stooping, and muscle tensing during symptomatic episodes—particularly effective in patients under 60 years with prodromal symptoms 1
• Elevate the head of bed by 10 degrees during sleep to prevent nocturnal polyuria and supine hypertension 1
• Advise gradual staged movements with postural changes 1

Compression Garments

• Use waist-high compression stockings (30-40 mmHg) 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 1

Step 3: Pharmacological Treatment (When Non-Pharmacological Measures Fail)

First-Line: Midodrine

• Start midodrine 2.5-5 mg three times daily 1, 3
• Midodrine has the strongest evidence base among pressor agents, with three randomized placebo-controlled trials demonstrating efficacy 1
• Avoid the last dose after 6 PM (take at least 3-4 hours before bedtime) to prevent supine hypertension during sleep 1, 3
• Increases standing systolic BP by 15-30 mmHg for 2-3 hours 1
• Monitor carefully for supine hypertension (BP >200 mmHg systolic possible) 3
• Use cautiously with cardiac glycosides, beta blockers, or other agents that reduce heart rate 3

Second-Line: Fludrocortisone (If Midodrine Insufficient)

• Start fludrocortisone 0.05-0.1 mg once daily, titrate to 0.1-0.3 mg daily 1
• Acts through sodium retention and vessel wall effects 1
• Contraindicated in active heart failure, severe renal disease, or pre-existing supine hypertension 1
• Monitor for hypokalemia, supine hypertension, peripheral edema, and congestive heart failure 1
• Evidence quality is limited with only very low-certainty evidence from small, short-term trials 1

Combination Therapy

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

Alternative Agents

Droxidopa:

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

Pyridostigmine:

• Beneficial for refractory orthostatic hypotension in elderly patients 1
• Favorable side effect profile compared to fludrocortisone (no fluid retention or supine hypertension) 1, 2
• Common side effects include nausea, vomiting, abdominal cramping, sweating, and urinary incontinence 1

Step 4: Treatment Goals and Monitoring

• The therapeutic goal is minimizing postural symptoms and improving functional capacity, NOT restoring normotension 1
• Measure blood pressure after 5 minutes lying/sitting, then at 1 and 3 minutes after standing to document orthostatic changes 1
• Monitor for supine hypertension development, which can cause end-organ damage 1
• Continue midodrine only for patients who report significant symptomatic improvement 3
• Reassess within 1-2 weeks after medication changes 1

Special Populations

Patients with Both Hypertension and Orthostatic Hypotension:

• Test for orthostatic hypotension before starting or intensifying any blood pressure-lowering medication 2
• Prefer long-acting dihydropyridine calcium channel blockers or RAS inhibitors as first-line antihypertensives 2
• Avoid beta-blockers unless compelling indications exist 2

Diabetic Patients:

• Assess for cardiovascular autonomic neuropathy 1
• Consider pyridostigmine, which does not cause fluid retention or supine hypertension 2

Elderly/Frail Patients (≥85 years):

• Long-acting dihydropyridine calcium channel blockers or RAS inhibitors preferred if antihypertensive therapy needed 2
• Avoid thiazide diuretics, which often cause orthostatic hypotension and reduced renal function 2

Critical Pitfalls to Avoid

• Do not simply reduce doses of offending antihypertensives—switch to alternative agents 1, 2
• Never allow patients to take midodrine if they will be supine for extended periods 3
• Do not use fludrocortisone in patients with heart failure or supine hypertension 1
• Avoid combining midodrine with other vasoconstrictors (phenylephrine, pseudoephedrine, ephedrine) without close blood pressure monitoring 3
• Balance the risk of falls from orthostatic hypotension against cardiovascular protection from antihypertensives 1