What is the diagnosis and treatment for orthostatic hypotension?

From the Guidelines

Orthostatic hypotension is a condition characterized by a sudden drop in blood pressure upon standing, resulting in symptoms such as dizziness, lightheadedness, and fainting.

Diagnosis

Diagnosis of orthostatic hypotension is made by measuring a drop of ≥20/10 mmHg in blood pressure 1 and/or 3 min after standing following a 5-min period in the seated or lying position 1.

Treatment

Treatment typically involves increasing fluid and salt intake, as well as medications like fludrocortisone (0.1-0.2 mg daily) and midodrine (2.5-10 mg three times daily) 1.

• Other treatment options include:
  • Physical counter-pressure maneuvers to help increase blood pressure 1
  • Compression garments to improve blood flow 1
  • Droxidopa to increase blood pressure 1
  • Pyridostigmine (30-60 mg three times daily) in severe cases to enhance blood pressure regulation 1
• Patients are also advised to:
  • Rise slowly from a seated or recumbent position
  • Avoid prolonged standing or strenuous activities
  • Use elastic garments over the legs and abdomen to improve blood flow 1
  • Drink water rapidly to help increase blood pressure 1
  • Avoid large meals rich in carbohydrates to prevent postprandial hypotension 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 diagnosis of orthostatic hypotension is not explicitly stated in the provided drug labels, but it is implied to be a condition characterized by a significant drop in blood pressure when standing, resulting in symptoms such as dizziness, lightheadedness, and unsteadiness. The treatment for orthostatic hypotension includes:

• Non-pharmacologic treatment:
  • Support stockings
  • Fluid expansion
  • Lifestyle alterations
• Pharmacologic treatment: Midodrine hydrochloride tablets, which can cause marked elevation of supine blood pressure, and should be used in patients whose lives are considerably impaired despite standard clinical care 2.

From the Research

Diagnosis of Orthostatic Hypotension

• Orthostatic hypotension is defined by a drop in blood pressure of at least 20mmHg for systolic blood pressure and at least 10mmHg for diastolic blood pressure within 3minutes of standing up 3
• It is characterized by a fall in blood pressure on assuming an upright position, resulting from the inability of the autonomic nervous system to adequately compensate for the blood that pools in the lower extremities 4
• Diagnosis involves a thorough review of patient symptomatology combined with appropriate clinical tests to narrow the differential diagnosis and pinpoint the etiology 4

Treatment of Orthostatic Hypotension

• Treatment always requires education of the patient regarding triggering situations and physiological countermanoeuvers 3
• Non-pharmacologic measures include optimizing blood volume, decreasing postural venous pooling, reducing heat and post-prandial induced vasodilation, emphasizing physical conditioning, and minimizing nocturnal diuresis 5
• Pharmacologic treatment may sometimes be necessary and mainly relies on volume expansion by fludrocortisone and/or a vasopressor agents such as midodrine 3, 4
• In cases of neurogenic orthostatic hypotension, treatment strategies and characteristics of drugs used for this condition are employed 6
• In heart failure patients, management of orthostatic hypotension is based mainly on non-pharmacologic interventions due to adverse effects of acceptable pharmacotherapy 7