What is the management of Orthostatic (postural) hypotension?

From the Guidelines

Orthostatic hypotension can be effectively managed through a combination of non-pharmacological and pharmacological approaches, with the most recent guidelines recommending a multifaceted approach to minimize postural symptoms and improve quality of life 1.

Non-Pharmacological Measures

• Implement lifestyle modifications including gradual position changes, adequate hydration (2-3 liters daily), and increased salt intake (8-10g/day if no contraindications) to help maintain blood pressure.
• Use compression stockings and avoid triggers like hot environments, large meals, and alcohol.
• Physical countermaneuvers such as crossing legs while standing, tensing lower body muscles, and performing isometric exercises can help maintain blood pressure.

Pharmacological Measures

• Consider fludrocortisone (starting at 0.1mg daily, maximum 0.3mg daily) which enhances sodium retention and increases blood volume.
• Midodrine (2.5-10mg three times daily, last dose before 6pm) directly increases peripheral vascular resistance.
• Droxidopa (100-600mg three times daily) converts to norepinephrine and raises blood pressure.
• For severe cases, pyridostigmine (30-60mg three times daily) may help by enhancing sympathetic ganglionic transmission.

Monitoring and Adjustment

• Regular monitoring of blood pressure in both sitting and standing positions is essential to assess treatment effectiveness and adjust therapy accordingly.
• The therapeutic goal is to minimize postural symptoms rather than to restore normotension, and treatment should be individualized based on patient response and tolerance to therapy 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 management of orthostatic hypotension with midodrine includes:

• Non-pharmacologic treatment: such as support stockings, fluid expansion, and lifestyle alterations
• Pharmacologic treatment: midodrine hydrochloride tablets, which can cause marked elevation of supine blood pressure, and should be used with caution in patients with certain medical conditions, such as renal or hepatic impairment 2
• Monitoring: blood pressure should be monitored carefully, especially when midodrine is used concomitantly with other agents that cause vasoconstriction 2

From the Research

Orthotic Hypotension Management

• Orthostatic hypotension (OH) is a debilitating disorder characterized by a drop in blood pressure when in the upright position, and its management involves several pharmacologic and lifestyle modifications 3.
• The treatment of OH is aimed at decreasing the symptoms, mainly the falls, increasing the standing time, and improving the activities of daily life 3.
• A recent expert consensus outlined the management of orthostatic hypotension and included 4 sequential steps:
  • Review medications and modify or remove those that may aggravate or cause OH
  • Non-pharmacologic measures
  • Pharmacologic measures
  • Treatment combinations 3.
• Non-pharmacological measures are aimed at optimizing blood volume, decreasing postural venous pooling, reducing heat and post-prandial induced vasodilation, emphasizing physical conditioning, and minimizing nocturnal diuresis 3.
• Fludrocortisone is a mineralocorticoid that increases blood volume and blood pressure, and is considered the first- or second-line pharmacological therapy for orthostatic hypotension alongside mechanical and positional measures 4.
• The evidence is very uncertain about the effects of fludrocortisone on blood pressure, orthostatic symptoms or adverse events in people with orthostatic hypotension and diabetes or Parkinson disease 4.
• Management and prognosis of orthostatic hypotension vary according to the underlying cause, with the main distinction being whether orthostatic hypotension is neurogenic or non-neurogenic 5.
• A stepwise, individualised, and primarily non-pharmacological approach to the management of orthostatic hypotension is recommended, which could include the cessation of blood pressure lowering drugs, adoption of lifestyle measures, and treatment with pharmacological agents in selected cases 5.