From the Guidelines
Orthostatic hypotension should be treated with a combination of non-pharmacological and pharmacological approaches, prioritizing lifestyle modifications and physical countermaneuvers, and considering medications like midodrine, droxidopa, and fludrocortisone as needed, as recommended by the most recent guidelines 1. The treatment of orthostatic hypotension aims to minimize postural symptoms rather than restore normotension.
- Non-pharmacological measures include:
- Ensuring adequate salt intake
- Avoiding medications that aggravate hypotension
- Using compressive garments over the legs and abdomen
- Physical activity and exercise to avoid deconditioning
- Volume repletion with fluids and salt
- Physical countermaneuvers like crossing legs while standing, tensing lower body muscles, and performing isometric exercises can help maintain blood pressure.
- Medications such as midodrine (2.5-10mg three times daily) and droxidopa (100-600mg three times daily) are approved by the FDA for the treatment of orthostatic hypotension, and fludrocortisone (starting at 0.1mg daily, maximum 0.3mg daily) may also be considered.
- Regular monitoring of blood pressure in both sitting and standing positions is essential to assess treatment effectiveness, as stated in the guidelines 1.
- The therapeutic goal is to minimize postural symptoms rather than to restore normotension, and most patients require both nonpharmacologic measures and pharmacologic measures, as recommended by the guidelines 1.
- Supine blood pressure tends to be much higher in these patients, often requiring treatment of blood pressure at bedtime with shorter-acting drugs that also affect baroreceptor activity, as mentioned in the guidelines 1.
- Alternatives can include enalapril if patients are unable to tolerate preferred agents, as stated in the guidelines 1.
- Midodrine and droxidopa are approved by the FDA for the treatment of orthostatic hypotension, as recommended by the guidelines 1. The most recent guidelines 1 provide the best approach to treating orthostatic hypotension, and should be followed in clinical practice.
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
To treat orthostatic hypotension, midodrine hydrochloride tablets can be used, but only in patients whose lives are considerably impaired despite standard clinical care, including:
- Non-pharmacologic treatment (such as support stockings)
- Fluid expansion
- Lifestyle alterations Midodrine should be used with caution and patients should be monitored for supine hypertension. 2
From the Research
Treatment Options for Orthostatic Hypotension
- Non-pharmacological measures are often the first line of treatment, including:
- Reviewing and modifying medications that may exacerbate orthostatic hypotension 3
- Increasing fluid and salt intake 3, 4
- Eating smaller, more frequent meals 4
- Avoiding large carbohydrate-rich meals 5
- Limiting alcohol consumption 5
- Maintaining adequate hydration 5
- Adding salt to the diet 5
- Sleeping with the head of the bed elevated 4, 6
- Pharmacological measures may be used in conjunction with non-pharmacological measures, including:
- Fludrocortisone, a mineralocorticoid that increases blood volume and blood pressure 3, 7, 5, 6
- Midodrine, a sympathomimetic agent that increases blood pressure 5, 6
- Droxidopa, a norepinephrine precursor that increases blood pressure 5, 6
- Pyridostigmine, a cholinesterase inhibitor that increases blood pressure 7, 5
- Atomoxetine, a norepinephrine reuptake inhibitor that increases blood pressure 5, 6
- The choice of treatment should be guided by patient-specific factors, such as tolerability, adverse effects, and drug-drug and drug-disease interactions 5
Lifestyle Modifications
- Physical counter-maneuvers, such as leg crossing, leg muscle pumping/contractions, and bending forward, may help improve orthostatic hypotension 4
- Abdominal compression may also be effective in improving orthostatic hypotension 4
- Resistance exercises and aerobic exercises may help improve physical conditioning and reduce symptoms of orthostatic hypotension 4
Monitoring and Management
- Blood pressure and heart rate should be monitored regularly to assess the effectiveness of treatment 6
- Patients with neurogenic orthostatic hypotension may require more frequent monitoring and adjustments to their treatment plan 6
- The goal of treatment is to improve quality of life and reduce symptoms, rather than to normalize blood pressure 6