How is postural hypotension managed?

Management of Postural Hypotension

Begin with non-pharmacological interventions for all patients, and add midodrine as first-line pharmacological therapy when symptoms persist despite these measures, with fludrocortisone as an alternative or adjunct. 1

Initial Assessment and Reversible Causes

• Immediately review and discontinue or switch medications that worsen orthostatic hypotension, including diuretics, vasodilators, ACE inhibitors, and calcium channel blockers—switching to alternative therapy is essential, not simply dose reduction. 1
• Drug-induced autonomic failure is the most frequent cause of orthostatic hypotension. 1
• Evaluate for volume depletion, alcohol use, endocrine disorders, and neurogenic causes before initiating treatment. 1
• 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). 2, 1

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

Volume expansion and physical countermeasures form the foundation of treatment and must be implemented before or alongside pharmacological therapy. 1

Fluid and Salt Management

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

Physical Countermeasures

• Teach leg crossing, squatting, stooping, and muscle tensing during symptomatic episodes—these maneuvers increase mean arterial pressure by 10-15 mmHg by translocating blood from below the diaphragm to the chest, and are particularly effective in patients under 60 years with prodromal symptoms. 1, 3
• Use waist-high compression stockings (30-40 mmHg) and abdominal binders to reduce venous pooling. 1

Lifestyle 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. 2, 1
• Encourage physical activity and exercise to avoid deconditioning, which exacerbates orthostatic intolerance. 2, 1
• Advise gradual staged movements with postural change. 1

Pharmacological Management (When Non-Pharmacological Measures Are Insufficient)

The therapeutic goal is to minimize postural symptoms and improve functional capacity, NOT to restore normotension—aggressive blood pressure targets may worsen supine hypertension. 2, 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, with the last dose at least 3-4 hours before bedtime (avoid dosing after 6 PM) to prevent supine hypertension during sleep. 1, 4
• Midodrine is an alpha-1 adrenergic agonist that increases vascular tone through arteriolar and venous constriction, increasing standing systolic BP by 15-30 mmHg for 2-3 hours. 1
• FDA-approved specifically for symptomatic orthostatic hypotension. 4
• Use with caution in older males due to potential urinary retention (acts on alpha-adrenergic receptors of the bladder neck). 1, 4
• May cause slight vagal-mediated heart rate slowing, but benefits usually outweigh this concern. 1

Second-Line: Fludrocortisone

Add fludrocortisone if midodrine alone provides insufficient symptom control, or use as first-line in patients with hypovolemic features. 1

• Start at 0.05-0.1 mg once daily, titrate individually to 0.1-0.3 mg daily (maximum 1.0 mg daily). 2, 1
• Acts through sodium retention and vessel wall effects to increase plasma volume. 2, 1
• Monitor for supine hypertension (most important limiting factor), hypokalemia, congestive heart failure, and peripheral edema. 2, 1
• Avoid in patients with active heart failure, significant cardiac dysfunction, severe renal disease, or low serum albumin (risk of ankle edema). 1, 5
• Evidence quality is limited with only very low-certainty evidence from small, short-term trials. 6

Third-Line: Droxidopa

• Droxidopa is FDA-approved and particularly effective for neurogenic orthostatic hypotension in Parkinson's disease, pure autonomic failure, and multiple system atrophy, and may reduce falls. 2, 1

Alternative: Pyridostigmine

• Pyridostigmine may be beneficial in patients with syncope due to neurogenic orthostatic hypotension who are refractory to other treatments, with a favorable side effect profile (fewer side effects than fludrocortisone). 1
• Common side effects include nausea, vomiting, abdominal cramping, sweating, salivation, and urinary incontinence. 1

Combination Therapy

• For non-responders to monotherapy, consider combination therapy with midodrine and fludrocortisone. 1
• Carefully monitor for supine hypertension when combining vasoconstrictors. 1

Special Considerations for Supine Hypertension

Many patients with orthostatic hypotension develop severe supine hypertension, which subjects them to life-threatening target organ damage including left ventricular hypertrophy, coronary heart disease, flash pulmonary edema, heart failure, renal failure, stroke, and sudden death. 2

• Treat supine blood pressure at bedtime with shorter-acting drugs that affect baroreceptor activity: guanfacine or clonidine, shorter-acting calcium blockers (isradipine), or shorter-acting β-blockers (atenolol or metoprolol tartrate). 2
• Alternatives include enalapril if patients cannot tolerate preferred agents. 2
• Head-up bed position during sleep helps prevent supine hypertension. 1

Monitoring and Follow-Up

• Assess response by monitoring standing heart rate, blood pressure, and symptom improvement. 1
• Early review at 24-48 hours after medication initiation, intermediate follow-up at 1-2 weeks, and late follow-up at 3-6 months. 1
• Monitor for supine hypertension development, which can cause end-organ damage. 1
• Check electrolytes periodically with fludrocortisone due to mineralocorticoid effects causing potassium wasting. 1
• Continue midodrine only for patients who report significant symptomatic improvement. 4

Critical Pitfalls to Avoid

• Do not simply reduce the dose of BP-lowering medications—switch to alternative therapy entirely. 1
• Do not take the last dose of midodrine after 6 PM—this prevents supine hypertension during sleep. 1
• Do not use cardiac pacing for orthostatic hypotension with bradycardia unless there is documented intrinsic sinus node dysfunction causing symptomatic bradyarrhythmias independent of postural changes. 1
• Avoid combining multiple vasoconstrictors without careful blood pressure monitoring. 1
• Balance the risk of falls and injury from postural hypotension against cardiovascular protection—the goal is symptom relief, not normotension. 1