What are the treatment options 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, prioritizing midodrine or fludrocortisone as first-line agents based on the clinical context. 1

Initial Evaluation and Reversible Causes

Before initiating treatment, identify and eliminate reversible causes:

• Discontinue or switch offending medications rather than simply reducing doses—this is the principal treatment strategy when drug-induced orthostatic hypotension is suspected 1, 2
• Diuretics and vasodilators are the most frequent medication culprits 1, 2
• Alpha-1 blockers (doxazosin, prazosin, terazosin, tamsulosin) are strongly associated with orthostatic hypotension, especially in older adults 2, 3
• Assess for volume depletion, anemia, and endocrine disorders 1
• Measure blood pressure after 5 minutes of sitting/lying, then at 1 and 3 minutes after standing to confirm diagnosis 1

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

Fluid and Salt Optimization

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

Postural Modifications

• Elevate the head of the bed by 10 degrees during sleep to prevent nocturnal polyuria, maintain favorable fluid distribution, and reduce supine hypertension 1
• Teach gradual staged movements with postural changes 1
• Avoid prolonged standing and hot environments 1

Physical Counter-Maneuvers

• Leg crossing, squatting, stooping, and muscle tensing during symptomatic episodes—particularly effective in patients under 60 years with prodromal symptoms 1
• These maneuvers can be implemented immediately when symptoms begin 1

Compression Garments

• Waist-high compression stockings (30-40 mmHg) and abdominal binders reduce venous pooling 1
• Thigh-high compression alone is less effective than abdominal compression 1

Dietary Modifications

• Smaller, more frequent meals to reduce post-prandial hypotension 1
• Encourage physical activity and exercise to avoid deconditioning 1

Pharmacological Management (When Non-Pharmacological Measures Fail)

The therapeutic goal is minimizing postural symptoms and improving functional capacity, NOT restoring normotension. 1

First-Line Pharmacological Options

Midodrine (Preferred Initial Agent)

• Start at 2.5-5 mg three times daily, titrate up to 10 mg three times daily as needed 1, 4
• Last dose must be taken at least 3-4 hours before bedtime (not after 6 PM) to prevent supine hypertension during sleep 1, 4
• Increases standing systolic BP by 15-30 mmHg for 2-3 hours 1, 4
• Has the strongest evidence base among pressor agents with three randomized placebo-controlled trials 1
• FDA-approved for symptomatic orthostatic hypotension 4
• Common pitfall: Administering midodrine after 6 PM causes nocturnal supine hypertension 1

Fludrocortisone (Alternative or Adjunct to Midodrine)

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

Combination Therapy for Non-Responders

• Combine midodrine and fludrocortisone when monotherapy provides insufficient symptom control 1
• These agents work through complementary mechanisms (alpha-1 adrenergic stimulation vs. sodium retention) 1
• Ensure adequate salt (6-10g daily) and fluid (2-3L daily) intake as adjunctive measures 1

Second-Line Pharmacological Options

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

Pyridostigmine

• Consider for refractory orthostatic hypotension when first-line treatments fail 1
• Favorable side effect profile compared to fludrocortisone 1
• ACC/AHA/HRS guidelines support use in neurogenic orthostatic hypotension refractory to other treatments 1
• Common side effects include nausea, vomiting, abdominal cramping, sweating, salivation, and urinary incontinence 1

Special Populations

Patients with Concurrent Hypertension and Orthostatic Hypotension

• Prefer long-acting dihydropyridine calcium channel blockers or RAS inhibitors as first-line antihypertensive therapy 1, 2
• Avoid beta-blockers unless compelling indications exist 2
• Switch medications that worsen orthostatic hypotension rather than reducing doses 1, 2

Diabetic Patients

• Assess for cardiovascular autonomic neuropathy 1
• Consider alpha-lipoic acid for painful diabetic neuropathy with potential autonomic benefits 1

Critical Monitoring Requirements

• Monitor supine blood pressure to detect treatment-induced supine hypertension—this is the most important limiting factor 1
• Measure orthostatic vital signs at each follow-up visit 1
• Reassess within 1-2 weeks after medication changes 1
• Check electrolytes, BUN, and creatinine if using fludrocortisone 1
• Balance benefits of increasing standing BP against risk of worsening supine hypertension 1

Common Pitfalls to Avoid

• Do NOT simply reduce the dose of offending medications—switch to alternatives instead 1, 2
• Do NOT administer midodrine after 6 PM due to supine hypertension risk 1
• Do NOT use fludrocortisone in patients with heart failure or supine hypertension 1
• Do NOT combine multiple vasodilating agents (ACE inhibitors + calcium channel blockers + diuretics) without careful monitoring 1
• Do NOT overlook volume depletion as a contributing factor 1
• Avoid medications that exacerbate orthostatic hypotension when possible, including psychotropic drugs, diuretics, and alpha-adrenoreceptor antagonists 1