I am taking losartan and experiencing dizziness, light‑headedness, blurry vision, fatigue, and nausea on standing; could this be orthostatic hypotension and how should I manage it?

Losartan-Induced Orthostatic Hypotension: Diagnosis and Management

Your symptoms—dizziness, light-headedness, blurry vision, fatigue, and nausea occurring immediately upon standing—are classic for orthostatic hypotension, most likely caused or worsened by losartan. 1, 2

Confirm the Diagnosis

Measure orthostatic vital signs properly:

• Lie supine for 5 minutes, then record blood pressure and heart rate 1, 2
• Stand up and measure again at 1 minute and 3 minutes 1, 2
• Orthostatic hypotension is confirmed if systolic BP drops ≥20 mmHg, diastolic BP drops ≥10 mmHg, or systolic BP falls below 90 mmHg within 3 minutes 1, 2
• If you have baseline hypertension, a systolic drop ≥30 mmHg should be considered diagnostic 2

Key distinguishing feature: In classic orthostatic hypotension, your heart rate increase will be blunted (typically <10 beats per minute), whereas conditions like POTS show a heart rate jump ≥30 bpm. 1, 2 The immediate onset of symptoms upon standing (within seconds to 3 minutes) points to classic orthostatic hypotension rather than vasovagal syncope, which develops after several minutes of standing. 1

Immediate Management Steps

1. Medication Review (First Priority)

Losartan is a recognized cause of orthostatic hypotension. 1, 3 Contact your prescribing physician immediately to:

• Reduce the losartan dose or discontinue it temporarily 1, 4, 5
• Review all other medications—diuretics, alpha-blockers, and other antihypertensives commonly worsen orthostatic hypotension 2, 3
• Do not stop losartan on your own if you have heart failure or diabetic kidney disease, as abrupt discontinuation may cause harm; dose adjustment under supervision is safer 4

2. Non-Pharmacologic Measures (Start Immediately)

These are first-line treatment per European Society of Cardiology guidelines: 1

• Increase salt intake to 10–12 grams daily (unless contraindicated by heart failure or kidney disease) 1, 4
• Increase fluid intake to 2–3 liters daily 1, 4
• Wear compression stockings (30–40 mmHg) from foot to waist to reduce venous pooling 1, 4
• Use physical counterpressure maneuvers when symptoms start: cross your legs, tense thigh and buttock muscles, or squat 1
• Avoid triggers: prolonged standing, hot environments, large meals, and rapid postural changes 1, 2
• Elevate the head of your bed 10–20 degrees to reduce supine hypertension and improve morning orthostatic tolerance 4, 5

3. Rule Out Other Reversible Causes

• Dehydration or blood loss can precipitate orthostatic hypotension in anyone taking antihypertensives 2, 4
• Autonomic failure (primary or secondary to Parkinson's disease, diabetes) should be considered if symptoms persist despite medication adjustment 2, 6, 5

When to Consider Pharmacologic Treatment

Only if non-pharmacologic measures fail after 2–3 months and symptoms remain disabling: 1, 4

• Midodrine 5–10 mg three times daily (α₁-agonist that raises BP by 15–30 mmHg within 1 hour) 4, 6
• Fludrocortisone 0.1–0.2 mg daily (promotes sodium retention and volume expansion) 4, 6
• Droxidopa (approved for neurogenic orthostatic hypotension in Parkinson's disease and related conditions) 6

Critical Pitfalls to Avoid

• Do not assume your hypertension requires aggressive treatment if you have orthostatic hypotension—recent evidence suggests intensive BP control may actually reduce orthostatic hypotension risk in some patients, but this requires individualized assessment. 7
• Do not delay standing measurements beyond 3 minutes during orthostatic testing, as this misses classic orthostatic hypotension and may falsely suggest delayed orthostatic hypotension. 1, 5
• Do not ignore supine hypertension—many patients with orthostatic hypotension have elevated BP when lying down, which complicates treatment and increases cardiovascular risk. 2, 5
• Do not dismiss symptoms as "just dizziness"—orthostatic hypotension increases risk of falls, cardiovascular events, and mortality. 2, 4, 7

Prognosis and Follow-Up

Orthostatic hypotension associated with medication is often reversible once the offending drug is adjusted or stopped. 4, 3 However, if symptoms persist despite medication changes, further evaluation for autonomic failure is warranted. 2, 5 Reassess orthostatic vital signs every 3 months initially to monitor treatment response. 1