What are the management options for orthostatic dizziness?

Management of Orthostatic Dizziness

Begin with non-pharmacological measures as first-line treatment, and if symptoms persist despite these interventions, initiate midodrine as the first-line pharmacological agent, with fludrocortisone as an alternative or adjunctive therapy. 1

Initial Assessment and Reversible Causes

• Confirm orthostatic hypotension by measuring blood pressure after 5 minutes of lying/sitting, then at 1 and 3 minutes after standing (a drop of ≥20 mmHg systolic or ≥10 mmHg diastolic confirms the diagnosis). 1
• Identify and discontinue medications that exacerbate orthostatic symptoms, including psychotropic drugs, diuretics, α-adrenoreceptor antagonists (like doxazosin, prazosin, terazosin), centrally-acting antihypertensives (clonidine, methyldopa), and vasodilators. 2, 1, 3
• Switch problematic blood pressure medications to alternatives rather than simply reducing the dose—long-acting dihydropyridine calcium channel blockers or RAS inhibitors are preferred if antihypertensive therapy is needed. 1, 3
• Evaluate for volume depletion, neurogenic causes, and endocrine disorders. 1

Non-Pharmacological Management (First-Line)

These measures should be implemented in all patients before considering pharmacological treatment. 2, 1

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 (if not contraindicated). 2, 1
• Acute water ingestion of ≥480 mL provides temporary relief, with peak effect at 30 minutes. 1

Postural Strategies

• Teach gradual staged movements with postural changes—avoid rapid standing. 2, 1
• Elevate the head of the bed by 10 degrees during sleep to prevent nocturnal polyuria, maintain favorable fluid distribution, and reduce supine hypertension. 1

Physical Counter-Maneuvers

• Implement leg-crossing, squatting, stooping, and muscle tensing during symptomatic episodes—these are particularly effective in patients under 60 years with prodromal symptoms. 2, 1

Compression Garments

• Use waist-high compression stockings (30-40 mmHg) and abdominal binders to reduce venous pooling. 1, 4

Dietary Modifications

• Recommend smaller, more frequent meals to reduce postprandial hypotension. 1
• Avoid large meals rich in carbohydrates. 2

Physical Activity

• Encourage mild isotonic exercise and physical activity to avoid deconditioning, which worsens orthostatic intolerance. 2, 1

Pharmacological Management (When Non-Pharmacological Measures Fail)

The therapeutic goal is to minimize postural symptoms and improve functional capacity, not to restore normotension. 1, 4

First-Line Pharmacological Agents

Midodrine (Strongest Evidence)

• Midodrine is the first-line pharmacological agent with the strongest evidence base among pressor agents, supported by three randomized placebo-controlled trials and FDA approval. 1, 5, 4
• Dosing: Start at 2.5-5 mg three times daily, with the first dose taken before arising. 2, 1, 5
• The last dose should be taken at least 3-4 hours before bedtime (avoid after 6 PM) to prevent supine hypertension during sleep. 2, 1, 5
• Can be titrated up to 10 mg three times daily based on response. 2, 5
• Mechanism: α1-adrenergic agonist that causes arteriolar and venous constriction, increasing standing systolic BP by 15-30 mmHg for 2-3 hours. 2, 5
• Adverse effects: Pilomotor reactions, pruritus, supine hypertension, bradycardia, gastrointestinal symptoms, and urinary retention. 2, 5
• Contraindications/Cautions: Use cautiously with cardiac glycosides, β-blockers, other vasoconstrictors, and in patients with urinary retention. 5

Fludrocortisone (Alternative First-Line)

• Fludrocortisone is another first-choice agent that acts through sodium retention and vessel wall effects. 2, 1
• Dosing: Start at 0.05-0.1 mg daily, titrate to 0.1-0.3 mg daily based on response (maximum 1.0 mg daily). 2, 1
• Mechanism: Mineralocorticoid that increases plasma volume through sodium retention and reduces vessel distensibility. 2, 1
• Adverse effects: Supine hypertension, hypokalemia, congestive heart failure, and peripheral edema. 2, 1
• Contraindications: Avoid in patients with active heart failure, significant cardiac dysfunction, or severe renal disease. 1
• Monitoring: Check electrolytes periodically for potassium wasting and monitor for supine hypertension. 1

Droxidopa (Alternative First-Line)

• Droxidopa is FDA-approved and particularly effective for neurogenic orthostatic hypotension in Parkinson's disease, pure autonomic failure, and multiple system atrophy. 1, 4
• May reduce falls in these populations. 1

Second-Line and Adjunctive Agents

Combination Therapy

• For non-responders to monotherapy, consider combining midodrine and fludrocortisone. 1

Pyridostigmine

• Consider pyridostigmine for refractory orthostatic hypotension in patients who have not responded to other treatments, particularly in elderly patients. 1, 4
• Advantage: Favorable side effect profile without causing fluid retention or supine hypertension. 1, 3
• Common side effects: Nausea, vomiting, abdominal cramping, sweating, salivation, and urinary incontinence. 1

Erythropoietin

• Consider in diabetic patients with hemoglobin <11 g/dL and severe cardiovascular autonomic neuropathy. 2
• Dosing: 25-75 U/kg subcutaneously or intravenously three times weekly, targeting hemoglobin of 12 g/dL. 2
• Mechanism: Increases red cell mass, corrects anemia, and has neurohumoral effects on vascular tone. 2

Other Agents (Limited Evidence)

• Desmopressin acetate: Useful for nocturnal polyuria and morning orthostatic hypotension. 2
• Somatostatin analogues (octreotide): For severe postprandial hypotension (strong recommendation, moderate evidence). 4
• Acarbose: For postprandial hypotension (strong recommendation, moderate evidence). 4

Critical Monitoring and Safety Considerations

• Monitor for supine hypertension, which is the most important limiting factor and can cause end-organ damage. 1, 5
• Measure blood pressure in supine, sitting, and standing positions at follow-up visits. 1
• Balance the goal of increasing standing blood pressure against the risk of supine hypertension. 2, 1
• Reassess patients within 1-2 weeks after medication changes. 1
• Monitor electrolytes periodically when using fludrocortisone due to mineralocorticoid effects. 1
• Avoid medications that worsen orthostatic hypotension when possible, including α-blockers, diuretics, and centrally-acting antihypertensives. 1, 3

Special Populations

Diabetic Patients with Cardiovascular Autonomic Neuropathy

• Cardioselective β-blockers without intrinsic sympathomimetic activity (metoprolol, nebivolol, bisoprolol) can be used to treat resting tachycardia associated with autonomic neuropathy. 2
• Consider α-lipoic acid for potential benefits on autonomic function (limited data). 2, 1

Elderly and Frail Patients

• Elderly patients are at substantially higher risk due to impaired baroreceptor response and altered pharmacokinetics. 1, 3
• Start with lower doses and titrate cautiously. 2
• Thiazide diuretics are particularly problematic in elderly patients, often causing orthostatic hypotension and reduced renal function. 3

Common Pitfalls to Avoid

• Do not simply reduce the dose of offending antihypertensive medications—switch to alternatives like long-acting dihydropyridine calcium channel blockers or RAS inhibitors instead. 1, 3
• Do not administer midodrine within 3-4 hours of bedtime to avoid nocturnal supine hypertension. 2, 1, 5
• Do not use fludrocortisone in patients with heart failure or significant cardiac dysfunction. 1
• Do not aim for normotension—the goal is symptom relief and improved functional capacity. 2, 1, 4
• Do not overlook medication review—drug-induced autonomic failure is the most frequent cause of orthostatic hypotension. 1