From the Guidelines
Outpatient management of hypotension should prioritize nonpharmacologic measures, such as ensuring adequate salt intake and using compressive garments, alongside pharmacologic measures like midodrine or droxidopa, as recommended by the most recent guidelines 1. The goal of treatment is to minimize postural symptoms rather than restore normotension.
- Initial treatment includes increasing fluid intake to 2-3 liters daily and increasing salt intake if not contraindicated by other conditions.
- Compression stockings can help improve venous return.
- Medications that may cause hypotension should be reviewed and potentially adjusted or discontinued.
- For persistent symptomatic hypotension, medications like fludrocortisone or midodrine may be prescribed.
- Midodrine works by constricting peripheral blood vessels, while fludrocortisone increases sodium retention and blood volume. Regular monitoring is essential, including home blood pressure measurements in both sitting and standing positions to assess for orthostatic hypotension. Patients should be educated to rise slowly from lying or sitting positions, avoid prolonged standing, and recognize symptoms requiring medical attention. Underlying conditions like adrenal insufficiency, dehydration, or medication side effects must be addressed as they are often the root cause of persistent hypotension in outpatient settings, as supported by recent studies 1. The use of midodrine and droxidopa is approved by the FDA for the treatment of orthostatic hypotension, as noted in 1. However, the most recent and highest quality study 1 should guide the treatment approach, focusing on a combination of nonpharmacologic and pharmacologic measures to minimize symptoms and improve quality of life.
From the FDA Drug Label
Midodrine hydrochloride tablets are indicated for the treatment of symptomatic orthostatic hypotension (OH) Because midodrine hydrochloride tablets can cause marked elevation of supine blood pressure (BP>200 mmHg systolic), it should be used in patients whose lives are considerably impaired despite standard clinical care, including non-pharmacologic treatment (such as support stockings), fluid expansion, and lifestyle alterations
Midodrine can be used for outpatient treatment of hypotension if the patient has symptomatic orthostatic hypotension and their life is considerably impaired despite standard clinical care.
- The patient should report significant symptomatic improvement to continue treatment. 2
From the Research
Treatment Options for Hypotension Outpatients
- Midodrine is a prodrug that undergoes enzymatic hydrolysis to the selective alpha 1-adrenoceptor agonist desglymidodrine after oral administration, and it has been shown to significantly increase 1-minute standing systolic blood pressure compared with placebo 3.
- Comparative studies have shown midodrine to have similar efficacy to dihydroergotamine mesylate, norfenefrine, fludrocortisone, and etilefrine, and to be more effective than dimetofrine and ephedrine in patients with orthostatic hypotension 3, 4.
- Midodrine is well tolerated, with the most commonly reported adverse events being piloerection, pruritus, paraesthesias, urinary retention, and chills, and the risk of supine hypertension can be reduced by taking the final daily dose at least 4 hours before bedtime 3, 4.
Non-Pharmacological Strategies
- Nonpharmacological strategies are the primary treatment for orthostatic hypotension, including discontinuing offending medications, switching medication administration to bedtime, avoiding large carbohydrate-rich meals, limiting alcohol, maintaining adequate hydration, adding salt to diet, and so on 5.
Pharmacological Therapies
- Midodrine and droxidopa possess the most evidence with respect to increasing blood pressure and alleviating symptoms of orthostatic hypotension 5.
- Fludrocortisone is considered the first- or second-line pharmacological therapy for orthostatic hypotension alongside mechanical and positional measures, but the evidence on its benefits and harms is very uncertain 6.
- Pyridostigmine and fludrocortisone can be used in patients who fail to respond to midodrine and droxidopa, and emerging evidence with low-dose atomoxetine is promising, especially in those with central autonomic failure 5.