From the Guidelines
Treatment for orthostatic hypotension should prioritize a combination of non-pharmacological and pharmacological approaches, with the goal of minimizing postural symptoms rather than restoring normotension, as recommended by the most recent guidelines 1.
Non-Pharmacological Measures
- Increase fluid intake to 2-3 liters daily and salt consumption to 8-10 grams per day
- Wear compression stockings that extend to the waist
- Practice physical countermaneuvers like leg crossing and muscle tensing when standing
- Rise slowly from lying or sitting positions
- Elevate the head of the bed by 4-6 inches
- Avoid alcohol, large meals, and hot environments
Pharmacological Measures
- Midodrine (2.5-10 mg three times daily, last dose before 6 PM) and droxidopa (100-600 mg three times daily) are approved by the FDA for the treatment of orthostatic hypotension and should be considered as first-line pharmacological treatments 1.
- Fludrocortisone (starting at 0.1 mg daily, maximum 0.3 mg daily) may be beneficial in patients with neurogenic orthostatic hypotension
- Pyridostigmine (30-60 mg three times daily) may help neurogenic orthostatic hypotension by enhancing sympathetic ganglionic transmission
- Other medications like guanfacine, clonidine, isradipine, atenolol, and metoprolol tartrate may be considered for treating supine hypertension, but their use should be individualized based on patient-specific factors 1.
Underlying Causes and Medication Adjustments
- Underlying causes of orthostatic hypotension should be addressed
- Medications that worsen the condition, such as certain antihypertensives, antidepressants, or diuretics, should be adjusted if possible 1.
From the FDA Drug Label
Midodrine hydrochloride tablets are indicated for the treatment of symptomatic orthostatic hypotension (OH) Because midodrine hydrochloride tablets can cause marked elevation of supine blood pressure (BP>200 mmHg systolic), it should be used in patients whose lives are considerably impaired despite standard clinical care, including non-pharmacologic treatment (such as support stockings), fluid expansion, and lifestyle alterations
Treatment for orthostatic hypotension is midodrine hydrochloride tablets, but it should only be used in patients who have not responded to standard clinical care, including:
- Non-pharmacologic treatment (such as support stockings)
- Fluid expansion
- Lifestyle alterations The patient should report significant symptomatic improvement for the treatment to be continued 2.
From the Research
Treatment Options for Orthostatic Hypotension
- Non-pharmacological measures are often the first line of treatment, including optimizing blood volume, decreasing postural venous pooling, reducing heat and post-prandial induced vasodilation, emphasizing physical conditioning, and minimizing nocturnal diuresis 3
- These measures may include increasing fluid and salt intake, wearing compression garments, and using physical counter-maneuvers such as leg crossing or leg muscle pumping/contractions 4
- Pharmacological interventions may be necessary for more severe symptoms, with options including midodrine, droxidopa, fludrocortisone, pyridostigmine, and atomoxetine 5, 6
- Midodrine has been shown to be effective in increasing blood pressure and alleviating symptoms of orthostatic hypotension, with a similar efficacy to other agents such as dihydroergotamine mesylate and fludrocortisone 7
Non-Pharmacological Interventions
- Sleeping with the head tilted up, eating smaller and more frequent meals, and drinking plenty of water may help alleviate symptoms of orthostatic hypotension 4
- Abdominal compression and physical maneuvers such as leg crossing and leg muscle pumping/contractions may also be effective 4
- Increasing fluid and salt intake, and wearing compression garments may help optimize blood volume and reduce postural venous pooling 3, 4
Pharmacological Interventions
- Midodrine is a well-tolerated and effective agent for the management of orthostatic hypotension, with a similar efficacy to other agents such as dihydroergotamine mesylate and fludrocortisone 7
- Droxidopa and fludrocortisone may also be effective in increasing blood pressure and alleviating symptoms of orthostatic hypotension 5, 6
- Pyridostigmine and atomoxetine may be used in patients who fail to respond to other agents, with emerging evidence suggesting that low-dose atomoxetine may be a viable alternative treatment option 5, 6