What management strategies are recommended for a patient experiencing orthostatic hypotension?

Management of Orthostatic Hypotension

Begin with non-pharmacological interventions and medication review, then add midodrine as first-line pharmacological therapy if symptoms persist, with fludrocortisone as second-line or combination therapy for refractory cases. 1

Immediate Assessment and Diagnosis

Confirm the diagnosis by measuring blood pressure after 5 minutes of lying/sitting, then at 1 and 3 minutes after standing. 2, 3 A drop of ≥20 mmHg systolic or ≥10 mmHg diastolic defines orthostatic hypotension. 2 In patients with supine hypertension, use a threshold of ≥30 mmHg systolic drop. 3

Identify and eliminate reversible causes immediately: 1, 3

• Drug-induced autonomic failure is the most frequent cause—diuretics and vasodilators are the primary culprits. 1, 3
• Alpha-1 blockers (doxazosin, prazosin, terazosin, tamsulosin) are strongly associated with orthostatic hypotension. 4
• Volume depletion from any cause. 1
• Alcohol consumption causes both autonomic neuropathy and volume depletion. 1

Switch medications that worsen orthostatic hypotension to alternatives rather than simply reducing the dose. 1, 3 For patients requiring continued antihypertensive therapy, use long-acting dihydropyridine calcium channel blockers or RAS inhibitors as first-line agents. 4

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

Implement these measures before or alongside pharmacological treatment: 1

Fluid and salt expansion:

• 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 (≥480 mL) provides temporary relief with peak effect at 30 minutes. 1

Physical countermeasures during symptomatic episodes: 1

• Leg crossing, squatting, stooping, and muscle tensing are particularly effective in patients under 60 years with prodromal symptoms. 1
• Teach 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

Positional strategies:

• Elevate the head of bed by 10 degrees during sleep to prevent nocturnal polyuria, maintain favorable fluid distribution, and ameliorate nocturnal hypertension. 1

Dietary modifications:

• Eat smaller, more frequent meals to reduce post-prandial hypotension. 1

Exercise:

• Encourage physical activity to avoid deconditioning, which worsens orthostatic intolerance. 1

Pharmacological Management

When non-pharmacological measures fail to adequately control symptoms, initiate pharmacological treatment with the goal of minimizing postural symptoms rather than restoring normotension. 1, 5

First-Line: Midodrine

Midodrine has the strongest evidence base among pressor agents, with three randomized placebo-controlled trials demonstrating efficacy. 1, 5

Dosing: 1, 5

• Start at 2.5-5 mg three times daily
• Increases standing systolic BP by 15-30 mmHg for 2-3 hours
• Can titrate up to 10 mg three times daily based on response
• Critical: Give the last dose at least 3-4 hours before bedtime (not later than 6 PM) to prevent supine hypertension during sleep 1

Mechanism: Alpha-1 adrenergic agonist that causes arteriolar and venous constriction, elevating blood pressure without stimulating cardiac beta-receptors. 5

FDA approval: Indicated for symptomatic orthostatic hypotension in patients whose lives are considerably impaired despite standard clinical care. 5

Second-Line: Fludrocortisone

Use fludrocortisone when midodrine alone provides insufficient symptom control or as an alternative first-line agent. 1, 6

Dosing: 1

• Start at 0.05-0.1 mg once daily
• Titrate individually to 0.1-0.3 mg daily (maximum 1.0 mg daily)
• Acts through sodium retention and vessel wall effects

Monitoring requirements: 1

• Check for supine hypertension (most important limiting factor)
• Monitor electrolytes periodically for hypokalemia
• Watch for congestive heart failure and peripheral edema

Contraindications: 1

• Active heart failure or significant cardiac dysfunction
• Pre-existing supine hypertension
• Severe renal disease where sodium retention would be harmful

Combination Therapy for Refractory Cases

For non-responders to monotherapy, combine midodrine and fludrocortisone. 1 These agents work through different mechanisms (alpha-1 adrenergic stimulation vs. sodium retention), making them complementary rather than redundant. 1

Ensure adequate salt (6-10g daily) and fluid (2-3L daily) intake as adjunctive measures when using combination therapy. 1

Alternative Agents

Droxidopa: 1, 7

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

Pyridostigmine: 1

• Beneficial for refractory orthostatic hypotension in elderly patients
• Favorable side effect profile compared to fludrocortisone
• Does not cause fluid retention or supine hypertension
• Common side effects: nausea, vomiting, abdominal cramping, sweating

Monitoring and Follow-Up

Measure blood pressure in both supine and standing positions at each follow-up visit to detect treatment-induced supine hypertension. 1

Reassess patients within 1-2 weeks after medication changes. 1

Monitor for adverse effects: 1

• Supine hypertension (can cause end-organ damage)
• Electrolyte abnormalities with fludrocortisone
• Falls and functional status

The therapeutic objective is minimizing postural symptoms and improving functional capacity, not restoring normotension. 1, 7, 8

Critical Pitfalls to Avoid

Do not simply reduce the dose of offending medications—switch to alternatives. 1, 3

Do not administer midodrine after 6 PM. 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

Do not inappropriately withhold beneficial medications (ACE inhibitors for heart failure, post-MI, diabetes, chronic kidney disease) simply because orthostatic hypotension is present—instead, optimize management of the orthostatic hypotension. 4