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

Management of Orthostatic Hypotension

Start with non-pharmacological interventions first, and only add medications when lifestyle measures fail to adequately control symptoms—the goal is minimizing postural symptoms and preventing falls, not achieving normal blood pressure numbers. 1

Initial Assessment and Reversible Causes

Immediately discontinue or switch medications that worsen orthostatic hypotension rather than simply reducing doses. 1, 2

• Drug-induced autonomic failure is the most frequent cause, with diuretics and vasodilators being the primary culprits 1, 2
• Evaluate for volume depletion, alcohol use (which causes both autonomic neuropathy and volume depletion), and endocrine disorders 1
• Measure blood pressure after 5 minutes lying/sitting, then at 1 and 3 minutes after standing to confirm diagnosis (≥20 mmHg systolic or ≥10 mmHg diastolic drop) 1, 2

Common medications to discontinue or switch: alpha-1 blockers, diuretics, ACE inhibitors, and multiple vasodilating agents used together 1

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

Implement these measures before considering medications:

Fluid and Salt Management

• Increase fluid intake to 2-3 liters daily (unless contraindicated by heart failure) 1
• Increase salt intake to 6-9 grams daily (unless contraindicated) 1
• Acute water ingestion of ≥480 mL provides temporary relief with peak effect at 30 minutes 1
• Paradoxically, plain water is more effective than salt water for acute pressor response 3

Physical Countermeasures

• Teach leg crossing, squatting, stooping, and muscle tensing during symptomatic episodes—particularly effective in patients under 60 years with prodromal symptoms 1
• Implement 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 and Dietary Modifications

• Elevate head of bed by 10 degrees during sleep to prevent nocturnal polyuria, maintain favorable fluid distribution, and ameliorate nocturnal hypertension 1
• Eat smaller, more frequent meals to reduce postprandial hypotension 1
• Encourage physical activity and exercise to avoid deconditioning 1

Pharmacological Management (When Non-Pharmacological Measures Fail)

First-Line Medication: Midodrine

Midodrine has the strongest evidence base among pressor agents, with three randomized placebo-controlled trials demonstrating efficacy. 1, 4

• Starting dose: 2.5-5 mg three times daily 1, 4
• Titration: Individually titrate up to 10 mg two to four times daily based on response 1
• Effect: Increases standing systolic BP by 15-30 mmHg for 2-3 hours 1, 4
• Critical timing: Last dose must be taken at least 3-4 hours before bedtime (not later than 6 PM) to prevent supine hypertension during sleep 1, 4
• Mechanism: Alpha-1 adrenergic agonist causing arteriolar and venous constriction without cardiac beta stimulation 4

Monitoring for midodrine:

• Check for supine hypertension (most important limiting factor) 1
• Monitor for bradycardia (pulse slowing, increased dizziness, syncope) 4
• Avoid in patients with urinary retention, as it acts on bladder neck alpha receptors 4

Alternative First-Line: Droxidopa

• FDA-approved and particularly effective for neurogenic orthostatic hypotension in Parkinson's disease, pure autonomic failure, and multiple system atrophy 1, 2
• May reduce falls 1

Second-Line or Combination Therapy: Fludrocortisone

Add fludrocortisone if midodrine alone provides insufficient symptom control, or use as monotherapy if midodrine is contraindicated. 1, 4

• Starting dose: 0.05-0.1 mg once daily 1, 2
• Titration: Individually titrate to 0.1-0.3 mg daily (maximum 1.0 mg daily) 1, 2
• Mechanism: Mineralocorticoid causing sodium retention and vessel wall effects 1

Contraindications for fludrocortisone:

• Active heart failure or significant cardiac dysfunction 1
• Pre-existing supine hypertension 1
• Severe renal disease where sodium retention would be harmful 1

Monitoring for fludrocortisone:

• Check for supine hypertension (most important) 1
• Monitor electrolytes periodically for hypokalemia 1
• Watch for congestive heart failure and peripheral edema 1
• Evidence quality is limited (very low-certainty evidence from small, short-term trials) 1

Combination Therapy

For non-responders to monotherapy, combine midodrine and fludrocortisone—they work through complementary mechanisms (alpha-1 stimulation vs. sodium retention). 1

Refractory Cases: Pyridostigmine

• Consider for refractory orthostatic hypotension in elderly patients who have not responded to other treatments 1
• Has a favorable side effect profile compared to alternatives 1
• Common side effects: nausea, vomiting, abdominal cramping, sweating, salivation, urinary incontinence 1

Special Populations

Patients with Concurrent Hypertension

• Switch to long-acting dihydropyridine calcium channel blockers (e.g., amlodipine) or RAS inhibitors as first-line antihypertensive therapy 1
• Avoid combining multiple vasodilating agents (ACE inhibitors + calcium channel blockers + diuretics) without careful monitoring 1

Diabetic Patients

• Assess for cardiovascular autonomic neuropathy 1
• Consider alpha-lipoic acid for painful diabetic neuropathy and potentially beneficial autonomic function 1

Patients on Hemodialysis

• Midodrine is removed by dialysis; adjust timing accordingly 4

Patients with Renal Impairment

• Start midodrine at 2.5 mg due to renal elimination of active metabolite 4
• Assess renal function before initiating therapy 4

Monitoring and Follow-Up

• Reassess within 1-2 weeks after medication changes 1
• Monitor orthostatic vital signs at each follow-up visit 1
• The therapeutic goal is minimizing postural symptoms and improving functional capacity, NOT restoring normotension 1, 2
• Balance the risk of falls and injury from postural hypotension against cardiovascular protection 1

Critical Pitfalls to Avoid

• Do NOT simply reduce the dose of offending medications—switch to alternative therapy 1, 2
• Do NOT administer midodrine after 6 PM 1
• Do NOT use fludrocortisone in patients with heart failure or supine hypertension 1
• Do NOT overlook volume depletion as a contributing factor 1
• Do NOT use beta-blockers for orthostatic hypotension—they are not effective and may aggravate bradycardia 1
• Avoid alpha-adrenergic blocking agents (prazosin, terazosin, doxazosin) as they antagonize midodrine's effects 4