From the Guidelines
Management of orthostatic hypotension should prioritize non-pharmacological approaches, including increasing fluid intake to 2-3 liters daily and salt consumption to 10-20g per day, unless contraindicated, as well as physical countermeasures like compression stockings and maneuvers such as leg crossing and squatting, as recommended by the most recent guidelines 1.
Non-Pharmacological Management
- Increase fluid intake to 2-3 liters daily and salt consumption to 10-20g per day, unless contraindicated by heart failure or hypertension
- Use physical countermeasures like compression stockings, abdominal binders, and maneuvers such as leg crossing and squatting to help maintain blood pressure when standing
- Avoid triggers like hot environments, large meals, alcohol, and rapid position changes
- Encourage physical activity and exercise to avoid deconditioning, which can exacerbate orthostatic intolerance
Pharmacological Management
- First-line options include midodrine (2.5-10mg three times daily, with the last dose at least 4 hours before bedtime) and fludrocortisone (0.1-0.3mg daily), as supported by recent guidelines 1
- Midodrine works as a peripheral alpha-1 agonist causing vasoconstriction, while fludrocortisone increases sodium retention and plasma volume
- For refractory cases, droxidopa (100-600mg three times daily) may be used, as approved by the FDA for the treatment of orthostatic hypotension 1
- Pyridostigmine (30-60mg three times daily) can help patients with autonomic failure by enhancing sympathetic ganglionic transmission
Monitoring and Treatment Adjustment
- Patients should monitor for supine hypertension as a side effect of these medications, and elevate the head of their bed by 30 degrees when sleeping
- Treatment should be tailored to the underlying cause of orthostatic hypotension, with regular blood pressure monitoring in both supine and standing positions to assess effectiveness, as recommended by recent guidelines 1
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 The indication is based on midodrine's effect on increases in 1-minute standing systolic blood pressure, a surrogate marker considered likely to correspond to a clinical benefit.
Management of Orthostatic Hypotension: Midodrine is indicated for the treatment of symptomatic orthostatic hypotension. The treatment should be used in patients whose lives are considerably impaired despite standard clinical care, including:
- Non-pharmacologic treatment (such as support stockings)
- Fluid expansion
- Lifestyle alterations Midodrine should be continued only for patients who report significant symptomatic improvement 2.
From the Research
Management of Orthostatic Hypotension
The management of orthostatic hypotension involves a combination of non-pharmacological and pharmacological interventions.
- Non-pharmacological measures are the primary treatment and include:
- Discontinuing offending medications 3, 4
- Avoiding large carbohydrate-rich meals 4
- Limiting alcohol 4
- Maintaining adequate hydration 5, 4
- Adding salt to diet 5, 4
- Sleeping with the head of the bed elevated 6
- Physical counter-maneuvers such as leg crossing, leg muscle pumping/contractions, and bending forward 5
- Pharmacological options include:
Non-Pharmacological Interventions
Non-pharmacological interventions can be effective in treating orthostatic hypotension, but the evidence is mixed and not all interventions have resulted in clinically meaningful changes in outcome 5.
- A systematic review found that physical maneuvers such as leg crossing, leg muscle pumping/contractions, and bending forward improved orthostatic hypotension 5
- Abdominal compression and sleeping with the head up in combination with pharmacological treatment were also found to be effective 5
- Eating smaller, more frequent meals and drinking 480 mL of water increased blood pressure 5
Pharmacological Interventions
Pharmacological interventions can help ameliorate symptoms of orthostatic hypotension, but the evidence is limited and the choice of medication should be guided by patient-specific factors 4.
- Midodrine and droxidopa possess the most evidence with respect to increasing blood pressure and alleviating symptoms 4
- Fludrocortisone can be used as first-line treatment, but it is associated with adverse events including renal and cardiac failure and increased risk of all-cause hospitalization 6
- Pyridostigmine and atomoxetine can be used in patients who fail to respond to other agents 6, 4