How should I manage orthostatic hypotension presenting as dizziness, light‑headedness, or syncope on standing in a patient who has recently started or increased trazodone, especially if the patient is older, dehydrated, has cardiac disease, or is on antihypertensive medications?

Managing Trazodone-Induced Orthostatic Hypotension

Immediately discontinue or reduce trazodone in patients presenting with orthostatic hypotension, dizziness, or syncope, as trazodone is a well-documented cause of medication-induced orthostatic hypotension that significantly increases fall and syncope risk, particularly in older adults. 1, 2, 3

Immediate Assessment and Trazodone Management

Confirm Orthostatic Hypotension

• Measure blood pressure after 5 minutes of lying/sitting, then at 1 and 3 minutes after standing 4, 5
• Orthostatic hypotension is defined as a drop in systolic BP ≥20 mmHg or diastolic BP ≥10 mmHg 4, 3
• Document whether symptoms (dizziness, lightheadedness, syncope) occur with position changes 4

Discontinue or Switch Trazodone

• The FDA label explicitly warns that trazodone causes hypotension, including orthostatic hypotension and syncope 1
• Trazodone users show a 23.8 mmHg systolic drop immediately upon standing versus 14.3 mmHg in non-users (p=0.037), and an 8.9 mmHg diastolic drop versus 1.6 mmHg (p=0.004) 2
• Trazodone increases syncope and fall risk to 58.3% versus 21.2% in non-users (p=0.001) 2
• The prevalence of orthostatic hypotension in patients receiving trazodone is 58%, making it one of the highest-risk medications 3
• Reducing or withdrawing medications that cause hypotension is a Class IIa recommendation for patients with syncope 4

Alternative Treatments for Depression/Insomnia

• Consider SSRIs or SNRIs for depression, which have lower orthostatic hypotension risk than trazodone 6
• For insomnia, consider non-pharmacologic interventions or alternative agents with lower hypotension risk 6
• The European Society of Cardiology emphasizes switching to alternative therapy rather than simply reducing the dose 5

Assess and Address Contributing Factors

Evaluate Volume Status

• Check for dehydration, acute blood loss, or hypovolemia as reversible contributors 4, 5
• Assess recent fluid intake, diuretic use, vomiting, diarrhea, or heat exposure 4

Review All Concurrent Medications

• Medication-induced orthostatic hypotension is the most frequent cause, with higher prevalence in older patients 4, 7
• Discontinue or switch other culprit medications: diuretics, vasodilators, alpha-1 blockers (doxazosin, terazosin, tamsulosin), centrally acting agents (clonidine), and other antihypertensives 4, 5
• The number of concurrent hypotension-causing medications directly correlates with orthostatic hypotension prevalence: 35% with zero medications, 58% with one, 60% with two, and 65% with three or more 3
• If the patient requires antihypertensive therapy, switch to long-acting dihydropyridine calcium channel blockers (e.g., amlodipine) or RAS inhibitors, which have lower orthostatic hypotension risk 5

Special Considerations in High-Risk Populations

• Older adults (≥75 years), those with cardiac disease, dehydration, or on multiple antihypertensives are at highest risk 1, 2, 3
• In diabetic patients >50 years with orthostatic hypotension, evaluate for cardiovascular autonomic neuropathy using cardiac autonomic reflex tests 5
• Frail elderly patients (≥85 years) with symptomatic orthostatic hypotension should have antihypertensive therapy deferred until office BP ≥140/90 mmHg 5

Non-Pharmacologic Management

Immediate Interventions

• Increase fluid intake to 2-3 liters daily and salt intake to 6-9 grams daily, unless contraindicated by heart failure, uncontrolled hypertension, or chronic kidney disease 4, 5
• Acute water ingestion (≥480 mL) provides temporary relief with peak effect at 30 minutes 5
• Teach physical counter-pressure maneuvers: leg crossing, squatting, stooping, and muscle tensing during symptomatic episodes 4, 5

Ongoing Measures

• Use waist-high compression stockings (30-40 mmHg) and abdominal binders to reduce venous pooling 5
• Elevate the head of the bed by 10 degrees during sleep to prevent nocturnal polyuria and supine hypertension 5
• Advise gradual positional changes: sit at bedside before standing, avoid prolonged standing 4
• Eat smaller, more frequent meals to reduce postprandial hypotension 5
• Encourage physical activity to avoid deconditioning, which worsens orthostatic intolerance 5

Pharmacologic Treatment (If Non-Pharmacologic Measures Fail)

First-Line Agents

• Midodrine 2.5-5 mg three times daily (alpha-1 agonist causing vasoconstriction), with the last dose at least 4 hours before bedtime to prevent supine hypertension 5
• Fludrocortisone 0.05-0.1 mg once daily (mineralocorticoid causing sodium retention), titrate to 0.1-0.3 mg daily 5
• Droxidopa is FDA-approved for neurogenic orthostatic hypotension in Parkinson's disease, multiple system atrophy, and pure autonomic failure 5, 8

Combination Therapy

• For inadequate response to monotherapy, combine midodrine with fludrocortisone, as they act via complementary mechanisms 5

Monitoring

• The therapeutic goal is minimizing postural symptoms, not restoring normotension 4, 5
• Monitor for supine hypertension (most important limiting factor with pressor agents) 5
• Check electrolytes periodically with fludrocortisone due to potassium wasting 5
• Measure both supine and standing BP at each visit 5

Common Pitfalls to Avoid

• Do not simply reduce the trazodone dose—switch to an alternative medication 5
• Do not overlook volume depletion as a contributing factor 5
• Do not combine multiple vasodilating agents (ACE inhibitors + calcium channel blockers + diuretics) without careful monitoring 5
• Do not administer midodrine after 6 PM due to supine hypertension risk 5
• Do not use fludrocortisone in patients with heart failure or supine hypertension 5
• Close supervision during medication adjustment is required due to potential worsening of supine hypertension or cardiac arrhythmias 4