Orthostatic Hypotension

Orthostatic Hypotension Treatment

Symptomatic BP drop ≥20/10 mmHg attributed to OH
Stop exacerbating meds + treat underlying causes
Inadequate response
Nonpharmacologic measures
  • Increase salt + water
  • Adjust activity, diet + positioning
  • Compression stockings / abdominal binder
Inadequate response
Symptoms partially improved with increased salt + water?
Yes
Start fludrocortisone 0.05 mg QAM Increase PRN by 0.05 mg q1-2 weeks. Max 0.2 mg/day.
Inadequate response
No
Start sympathomimetic agent
  • Midodrine 2.5 mg BID while awake. Titrate weekly. Max 10 mg TID.
  • Droxidopa 100 mg TID while awake. Titrate q2-3 days. Max 600 mg TID.
  • Avoid either med <3 hrs before bedtime.
Inadequate response
Add alternative first-line agent from different pharmacologic class
Inadequate response
Plasma norepinephrine >220 pg/mL?
Yes
Add/switch to atomoxetine.
Start 10 mg BID. Titrate PRN to 18 mg BID.
Inadequate response
No
Add/switch to alternative agent
  • Pyridostigmine
  • Erythropoietin
  • NSAID