What are the immediate recommendations for managing orthostatic (postural) hypotension in a patient?

Immediate Management of Orthostatic Hypotension

The first priority is to identify and eliminate reversible causes, particularly discontinuing or modifying offending medications (diuretics, vasodilators, antihypertensives), followed by nonpharmacologic interventions, and reserving pharmacologic therapy with midodrine or fludrocortisone for patients who remain significantly symptomatic despite these measures. 1, 2, 3

Initial Assessment and Diagnosis

Confirm the Diagnosis

• Measure blood pressure after 5 minutes of supine or sitting rest, then at 1 and 3 minutes after standing with the arm maintained at heart level throughout 4
• Orthostatic hypotension is defined as a decrease in systolic BP ≥20 mmHg or diastolic BP ≥10 mmHg within 3 minutes of standing 1, 4, 3
• Document associated symptoms: dizziness, lightheadedness, blurred vision, weakness, fatigue, syncope, or falls 3

Identify Reversible Causes

• Drug-induced autonomic failure is the most frequent cause - immediately review and discontinue or reduce offending agents 1:
  • Diuretics and vasodilators are the most important culprits 1
  • Alpha-blockers and beta-blockers (especially in elderly/frail patients) 5
  • Other antihypertensives causing excessive BP lowering 1
• Assess for volume depletion from dehydration, blood loss, or alcohol use 1, 3
• Evaluate for underlying conditions: autonomic neuropathy, cardiovascular disease, endocrine disorders 3

Immediate Nonpharmacologic Interventions (Class I Recommendations)

All patients should receive nonpharmacologic treatment as first-line therapy before considering medications. 1, 3

Volume Expansion Strategies

• Increase salt intake (add salt supplements to diet) 1
• Increase fluid intake to expand central volume 1
• Avoid large meals that cause splanchnic pooling 6

Physical Countermeasures

• Apply abdominal binders to reduce splanchnic venous pooling and improve venous return 6
• Use compression stockings (support stockings) 1
• Teach physical countermaneuvers: leg crossing, squatting, or muscle tensing before standing 3

Lifestyle Modifications

• Sleep with head-up tilt (>10 degrees elevation) 1
• Avoid prolonged standing and rapid postural changes 1
• Rise slowly from supine to sitting to standing positions 3
• Implement an exercise program to improve conditioning 1
• Avoid bedrest deconditioning - keeping patients mobile is crucial even during hospitalization 6

Environmental Adjustments

• Avoid trigger situations when possible 1
• Minimize exposure to heat and hot showers 3
• Have patients sit rather than stand when feasible (protected posture) 1

Pharmacologic Management (When Nonpharmacologic Measures Fail)

Pharmacologic therapy should only be initiated for patients whose lives are considerably impaired despite standard clinical care and who report significant symptomatic improvement after treatment initiation. 2, 3

First-Line Pharmacologic Agents

Midodrine (Alpha-1 Agonist)

• FDA-approved specifically for symptomatic orthostatic hypotension 2
• Increases vascular tone and elevates blood pressure by activating alpha-adrenergic receptors 2
• Typical dosing: 10 mg three times daily, with last dose not later than 6 PM to avoid supine hypertension 2
• Raises standing systolic BP by approximately 15-30 mmHg at 1 hour after dosing, with effects persisting 2-3 hours 2
• Critical warning: Can cause marked supine hypertension (>200 mmHg systolic) - monitor supine BP closely 2

Fludrocortisone (Mineralocorticoid)

• Proven beneficial for patients not responding to nonpharmacologic treatment 3
• Generally considered a first-choice drug along with midodrine 7
• Expands plasma volume through sodium retention 3

Alternative Agent: Pyridostigmine

• Proven beneficial as an alternative pharmacologic option 3
• May be particularly useful in patients who cannot tolerate midodrine or fludrocortisone 3

Droxidopa

• FDA-approved specifically for neurogenic orthostatic hypotension 5
• Consider in patients with autonomic failure 5

Special Considerations

Concomitant Supine Hypertension

• This is a common and challenging scenario - supine BP may be ≥200 mmHg in 22-45% of patients on midodrine 2
• Switch (rather than simply reduce) BP-lowering medications that worsen orthostatic hypotension to alternative therapies 5
• The treatment goal is not normalizing upright BP but increasing it above the cerebral autoregulation threshold to improve symptoms 6
• Confining patients to bed while using pressors only worsens supine hypertension and leads to pressure diuresis, perpetuating orthostatic hypotension 6

Elderly and Frail Patients

• Assess for orthostatic hypotension before starting or intensifying any BP-lowering medication 4, 5
• Avoid beta-blockers and alpha-blockers unless specifically indicated 5
• Consider deprescribing BP medications if BP drops with progressing frailty 5
• For patients ≥85 years or with moderate-to-severe frailty requiring hypertension treatment, use long-acting dihydropyridine calcium channel blockers or RAS inhibitors as first-line agents 5

Hospitalized Patients

• Use pressors as part of an orthostatic rehabilitation program rather than keeping patients at bedrest 6
• Avoid bedrest deconditioning to reduce hospital stay 6
• Regular monitoring of both standing and supine BP is essential 5

Common Pitfalls to Avoid

• Do not continue pharmacologic treatment indefinitely without reassessing symptomatic benefit - midodrine should only be continued for patients reporting significant symptomatic improvement 2
• Do not ignore supine hypertension - measure supine BP regularly in patients on pressor agents 2
• Do not prescribe midodrine doses after 6 PM - this increases risk of nocturnal supine hypertension 2
• Do not overlook medication review - drug-induced orthostatic hypotension is the most common reversible cause 1
• Do not keep patients on bedrest while treating with pressors - this worsens the condition through deconditioning and pressure diuresis 6