What medication is recommended for hypotension in a healthy adult outpatient?

From the Guidelines

For a healthy adult outpatient with low blood pressure, the first-line treatment should be non-pharmacological measures, and if symptoms persist, midodrine is a recommended medication, taken at 10 mg/day, individually tailored, with the first dose taken before arising and use avoided several hours before planned recumbency. When considering medication for low blood pressure in a healthy adult outpatient, it's crucial to weigh the potential risks against the benefits, aiming to minimize postural symptoms rather than restore normotension 1. The treatment should focus on symptomatic relief, and the choice of medication depends on the individual's response and the presence of any underlying conditions.

Non-Pharmacological Measures

Before considering medication, several non-pharmacological strategies can be employed:

• Identifying and addressing other causes of orthostatic hypotension, such as volume depletion
• Avoiding drugs that exacerbate postural symptoms, like psychotropic drugs, diuretics, and α-adrenoreceptor antagonists
• Educating patients on behavioral strategies, including gradual movements, mild isotonic exercise, head-up bed position during sleep, and physical counter-manoeuvres
• Increasing fluid and salt intake if not contraindicated, and using elastic garments over the legs and abdomen

Pharmacological Treatment

If symptoms persist despite non-pharmacological measures, pharmacological treatment may be considered. The options include:

• Midodrine, a peripheral selective α1-adrenergic agonist, which is a first-line drug for the treatment of symptomatic orthostatic hypotension, with dosing individually tailored up to 10 mg/day 1
• 9-α-fluorohydrocortisone, which acts through sodium retention and direct vasoconstriction, with an initial dose of 0.05–0.1 mg daily and individual titration up to 0.1–0.3 mg daily 1
• Other possible treatments, such as erythropoietin, desmopressin acetate, somatostatin analogues, caffeine, and acarbose, which may be considered based on the individual's specific needs and response to treatment 1

Monitoring and Supervision

It's essential to monitor blood pressure regularly and adjust the treatment as needed to avoid supine hypertension and other potential side effects. The treatment should be tailored to the individual's symptoms and response, with the goal of improving quality of life and reducing morbidity and mortality associated with low blood pressure.

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 medication for low blood pressure in a healthy adult outpatient is midodrine (PO), but it should be used with caution and only in patients whose lives are considerably impaired despite standard clinical care.

• Indication: Symptomatic orthostatic hypotension (OH)
• Key consideration: Risk of supine hypertension 2
• Precautions:
  • Monitor blood pressure carefully
  • Avoid concomitant use of drugs that increase blood pressure
  • Use with caution in patients with renal or hepatic impairment 2

From the Research

Medications for Low Blood Pressure in Healthy Adults

• Fludrocortisone is a mineralocorticoid that increases blood volume and blood pressure, and is considered a first- or second-line pharmacological therapy for orthostatic hypotension 3.
• Midodrine is a prodrug that increases standing systolic blood pressure and improves standing time and energy level, and is also used to treat orthostatic hypotension 4.
• Comparative studies have shown that midodrine has similar efficacy to fludrocortisone in patients with orthostatic hypotension 4.
• However, fludrocortisone has been associated with a higher risk of all-cause hospitalizations compared to midodrine in patients with orthostatic hypotension 5.

Treatment Persistence and Outcomes

• A retrospective cohort study found that the median persistence on treatment with fludrocortisone and midodrine was 254 and 259 days, respectively, and that overall duration of treatment with first-line medications was short and similar for both medications 6.
• The study also found that the adjusted hazard ratio for overall non-persistence on midodrine compared to fludrocortisone was 1.07 (95% CI: 0.90-1.28) 6.
• Another study found that treatment of orthostatic hypotension always requires education of the patient regarding triggering situations and physiological countermanoeuvers, and that pharmacological treatment may sometimes be necessary, mainly relying on volume expansion by fludrocortisone and/or a vasopressor agents such as midodrine 7.

Treatment Goals and Considerations

• The goal of therapy for orthostatic hypotension is the relief of symptoms and fall prevention, and there is no predefined blood pressure target 7.
• Treatment should be individualized and take into account the underlying cause of orthostatic hypotension, as well as the patient's medical history and current medications 3, 4, 7.