What is the diagnosis and treatment for orthostatic hypotension?

From the Guidelines

Orthostatic hypotension should be managed by implementing lifestyle changes and considering medications such as midodrine or droxidopa, as recommended by the most recent guidelines 1. To manage orthostatic hypotension, start by implementing lifestyle changes such as:

• Rising slowly from seated or lying positions
• Staying well-hydrated with 2-3 liters of water daily
• Increasing salt intake (if not contraindicated by other conditions)
• Wearing compression stockings
• Avoiding alcohol and large meals If symptoms persist, medications may be necessary. First-line pharmacological options include:
• Midodrine (ProAmatine) 2.5-10 mg three times daily, which constricts blood vessels
• Droxidopa (Northera) 100-600 mg three times daily, which is another option for neurogenic orthostatic hypotension These medications work by either increasing blood volume or constricting blood vessels to maintain blood pressure when standing. It's essential to monitor for supine hypertension (high blood pressure when lying down) as a side effect of these medications, so the last dose should be taken at least 3-4 hours before bedtime. Underlying causes such as dehydration, anemia, or medication side effects should also be addressed as they can contribute to or worsen orthostatic hypotension. Additionally, physical activity and exercise should be encouraged to avoid deconditioning, which is known to exacerbate orthostatic intolerance, and volume repletion with fluids and salt is critical 1.

Some key points to consider when managing orthostatic hypotension include:

• The therapeutic goal is to minimize postural symptoms rather than to restore normotension
• Most individuals require both nonpharmacologic measures and pharmacologic measures
• Supine blood pressure tends to be much higher in these individuals, often requiring treatment of blood pressure at bedtime with shorter-acting drugs
• Midodrine and droxidopa are approved by the FDA for the treatment of orthostatic hypotension 1.

Overall, managing orthostatic hypotension requires a comprehensive approach that includes lifestyle changes, medications, and addressing underlying causes. By following the most recent guidelines and considering the individual's specific needs, healthcare providers can help alleviate symptoms and improve quality of life for patients with orthostatic hypotension.

From the FDA Drug Label

Midodrine hydrochloride tablets are indicated for the treatment of symptomatic orthostatic hypotension (OH) Midodrine forms an active metabolite, desglymidodrine, that is an alpha1-agonist, and exerts its actions via activation of the alpha-adrenergic receptors of the arteriolar and venous vasculature, producing an increase in vascular tone and elevation of blood pressure. Administration of midodrine results in a rise in standing, sitting, and supine systolic and diastolic blood pressure in patients with orthostatic hypotension of various etiologies Standing systolic blood pressure is elevated by approximately 15 to 30 mmHg at 1 hour after a 10 mg dose of midodrine, with some effect persisting for 2 to 3 hours.

Midodrine is used to treat orthostatic hypotension. It works by increasing blood pressure through the activation of alpha-adrenergic receptors. The medication has been shown to elevate standing systolic blood pressure by approximately 15 to 30 mmHg at 1 hour after a 10 mg dose, with some effect lasting for 2 to 3 hours 2 2.

From the Research

Definition and Pathophysiology of Orthostatic Hypotension

• Orthostatic hypotension (OH) is a common cardiovascular disorder characterized by a blood pressure fall when standing from the supine to the erect position 3.
• It is considered a manifestation of dysfunction of the autonomic nervous system, caused or facilitated by several neurological or non-neurological diseases and conditions 3.

Clinical Significance and Prognostic Implications

• OH is highly prevalent in elderly and frail individuals and in patients with multiple comorbidities 3.
• It has been extensively studied and numerous prospective cohort studies support its association with adverse events, including coronary artery disease, heart failure, stroke, cognitive dysfunction, and mortality rates 3.

Treatment and Management

• Specific pharmacological and non-pharmacological interventions have been established for the treatment of OH, including volume expansion with fludrocortisone and sympathetic enhancement with midodrine, droxidopa, and norepinephrine reuptake inhibitors 4.
• Non-pharmacologic measures, such as the use of elastic compression stockings (ECS), can also be effective in managing OH, although issues related to practicality and patient compliance may limit their use 5.
• Management of OH is aimed at improving quality of life and reducing symptoms rather than at normalizing blood pressure 4.

Patient and Physician Perspectives

• Patients with OH may experience difficulty in applying ECS and discomfort, which can lead to non-compliance 5.
• Physicians may underestimate the scale of patient compliance with ECS, but correctly predict the main reasons for non-compliance, such as difficulty in application 5.