How is orthostatic hypotension treated in an adult with symptomatic drops in blood pressure upon standing?

Treatment of Orthostatic Hypotension

Yes, orthostatic hypotension has multiple effective treatments, starting with non-pharmacological measures and progressing to FDA-approved medications when lifestyle modifications fail to control symptoms. 1

Diagnostic Confirmation

Before initiating treatment, confirm the diagnosis by measuring blood pressure after 5 minutes of lying or sitting, then at 1 minute and 3 minutes after standing. 1 A drop of ≥20 mmHg systolic or ≥10 mmHg diastolic confirms orthostatic hypotension. 1, 2

Step 1: Identify and Remove Reversible Causes

The most frequent cause of orthostatic hypotension is medication-induced autonomic failure, particularly from diuretics and vasodilators. 1

High-Priority Medications to Discontinue:

• Alpha-1 blockers (doxazosin, prazosin, terazosin, tamsulosin) – these are the most problematic agents and should be stopped completely, not dose-reduced 1, 3
• Centrally-acting antihypertensives (clonidine, methyldopa) – must be tapered gradually to avoid rebound hypertension 3
• Beta-blockers – avoid unless compelling indications exist (heart failure, recent MI) 1
• Diuretics – especially thiazides in elderly patients with reduced renal function 3

Switch offending medications to alternatives rather than simply reducing doses. 1 For patients requiring continued antihypertensive therapy, long-acting dihydropyridine calcium channel blockers (e.g., amlodipine) or RAS inhibitors (ACE inhibitors/ARBs) are preferred first-line agents with minimal orthostatic impact. 1, 3

Step 2: Non-Pharmacological Management (First-Line for All Patients)

Volume Expansion:

• Increase fluid intake to 2–3 liters daily 1
• Increase salt consumption to 6–9 grams daily (unless contraindicated by heart failure or uncontrolled hypertension) 1
• Acute water ingestion of ≥480 mL provides temporary relief with peak effect at 30 minutes 1

Physical Countermeasures:

• Teach leg crossing, squatting, stooping, and muscle tensing during symptomatic episodes – particularly effective in patients under 60 years with prodromal symptoms 1
• Advise gradual staged movements when changing position; sit on bedside for 2–3 minutes before standing 1

Compression Garments:

• Use waist-high compression stockings (30–40 mmHg) and abdominal binders to reduce venous pooling 1

Positional Strategies:

• Elevate the head of the bed by 10 degrees during sleep to prevent nocturnal polyuria, maintain favorable fluid distribution, and ameliorate nocturnal hypertension 1

Dietary Modifications:

• Eat smaller, more frequent meals to reduce post-prandial hypotension 1

Physical Conditioning:

• Encourage regular physical activity and exercise to avoid deconditioning, which worsens orthostatic intolerance 1

Step 3: Pharmacological Treatment (When Non-Pharmacological Measures Fail)

The therapeutic goal is minimizing postural symptoms and improving functional capacity, NOT restoring normotension. 1

First-Line Pharmacological Agents:

Midodrine has the strongest evidence base among pressor agents, with three randomized placebo-controlled trials demonstrating efficacy. 1

• Starting dose: 2.5–5 mg three times daily at roughly 4-hour intervals during waking hours 1
• Titrate up to 10 mg three times daily based on symptom response 1
• Critical timing: Last dose must be taken at least 3–4 hours before bedtime (not after 6 PM) to prevent supine hypertension 1
• Effect: Increases standing systolic BP by 15–30 mmHg for 2–3 hours via peripheral α₁-adrenergic vasoconstriction 1

Fludrocortisone acts through sodium retention and vessel wall effects. 1

• Starting dose: 0.05–0.1 mg once daily 1
• Titrate to 0.1–0.3 mg daily based on clinical response 1
• Monitor for: supine hypertension, hypokalemia, congestive heart failure, and peripheral edema 1
• Contraindications: Active heart failure, significant cardiac dysfunction, severe renal disease, or pre-existing supine hypertension 1

Droxidopa is FDA-approved specifically for symptomatic neurogenic orthostatic hypotension. 4

• Particularly effective for: Parkinson's disease, pure autonomic failure, and multiple system atrophy 1
• Note: Effectiveness beyond 2 weeks has not been established; continued effectiveness should be assessed periodically 4
• Caution: Concomitant carbidopa therapy can diminish droxidopa's efficacy by inhibiting peripheral conversion to norepinephrine 1

Combination Therapy for Inadequate Response:

When monotherapy fails, combine midodrine with fludrocortisone because they act via complementary mechanisms (α₁-adrenergic vasoconstriction plus mineralocorticoid-mediated volume expansion). 1

Refractory Cases:

Pyridostigmine (60 mg three times daily) may be added for patients refractory to first-line treatments, particularly when supine hypertension is a concern. 1

• Advantage: Does not worsen supine blood pressure or cause fluid retention 1
• Mechanism: Enhances ganglionic sympathetic transmission by inhibiting acetylcholinesterase 1
• Common side effects: Nausea, vomiting, abdominal cramping, sweating, salivation, urinary incontinence 1

Critical Monitoring Requirements

• Measure both supine and standing blood pressure at each visit after 5 minutes lying/sitting, then at 1 and 3 minutes after standing 1
• Monitor for supine hypertension development – the most important limiting factor with pressor agents 1
• Check electrolytes periodically when using fludrocortisone due to mineralocorticoid effects causing potassium wasting 1
• Reassess within 1–2 weeks after medication changes 1

Common Pitfalls to Avoid

• Do NOT simply reduce the dose of offending medications – switch to alternatives instead 1
• Do NOT administer midodrine after 6 PM – risk of nocturnal supine hypertension 1
• Do NOT use fludrocortisone in patients with heart failure or supine hypertension 1
• Do NOT combine multiple vasodilating agents (ACE inhibitors + calcium channel blockers + diuretics) without careful monitoring 1
• Do NOT overlook volume depletion as a contributing factor 1

Special Populations

Elderly/Frail Patients (≥85 years):

Defer blood pressure-lowering treatment until office BP ≥140/90 mmHg in patients with pre-treatment symptomatic orthostatic hypotension, moderate-to-severe frailty, or limited life expectancy. 1 Target "as low as reasonably achievable" (ALARA principle) rather than strict 130/80 mmHg. 1

Diabetic Patients:

Assess for cardiovascular autonomic neuropathy in diabetic patients over 50 years with orthostatic hypotension, as this represents advanced autonomic failure and confers additional mortality risk. 1