From the Guidelines
Sertraline is not recommended as a first-line treatment for orthostatic hypotension. While some selective serotonin reuptake inhibitors (SSRIs) like sertraline may occasionally help with neurogenic orthostatic hypotension in specific cases, they are not standard therapy and could potentially worsen symptoms in some patients. First-line treatments for orthostatic hypotension typically include non-pharmacological approaches such as:
- Increasing fluid and salt intake
- Wearing compression stockings
- Performing counter-maneuvers like leg crossing
- Avoiding rapid position changes If medications are needed, midodrine (starting at 2.5-5mg three times daily) or fludrocortisone (starting at 0.1mg daily) are typically used first, as recommended by the 2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope 1. Droxidopa (100-600mg three times daily) may be considered for neurogenic orthostatic hypotension. The mechanism by which sertraline might occasionally help involves serotonergic effects on blood pressure regulation, but this effect is inconsistent and poorly understood, as noted in the K/DOQI clinical practice guidelines for cardiovascular disease in dialysis patients 1. If considering sertraline for a patient with orthostatic hypotension, it should be done cautiously with close monitoring of blood pressure and only after standard treatments have been tried.
From the Research
Orthostatic Hypotension and Sertraline
- Orthostatic hypotension is a condition characterized by an excessive fall in blood pressure while standing, resulting from a decrease in cardiac output or defective vasoconstrictor mechanisms 2.
- The use of sertraline, a selective serotonin reuptake inhibitor, has been studied in the context of orthostatic hypotension, particularly in patients with end-stage renal disease 3.
- A study found that sertraline hydrochloride reduced hemodialysis hypotension in some patients with end-stage renal disease, possibly by attenuating paradoxical sympathetic withdrawal 3.
- Another study discussed the effects of antidepressant drugs, including sertraline, on blood pressure, noting that selective serotonin reuptake inhibitors have limited effects on autonomic system activity and a lower impact on blood pressure 4.
Treatment Options for Orthostatic Hypotension
- Fludrocortisone, a mineralocorticoid, is considered a first- or second-line pharmacological therapy for orthostatic hypotension, alongside mechanical and positional measures 2.
- Midodrine, a prodrug that undergoes enzymatic hydrolysis to a selective alpha 1-adrenoceptor agonist, is also an effective therapeutic option for the management of orthostatic hypotension 5.
- Other pharmacologic options for orthostatic hypotension include volume expansion with fludrocortisone, sympathetic enhancement with midodrine, droxidopa, and norepinephrine reuptake inhibitors 6.
Sertraline's Mechanism of Action
- Sertraline's potential mechanism of action in reducing orthostatic hypotension involves its effects on serotoninergic pathways, which may influence blood pressure regulation 3, 4.
- The exact mechanism by which sertraline reduces orthostatic hypotension is not fully understood and may require further research to elucidate its effects on blood pressure regulation 3, 4.