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

References

  1. Freeman, R., Wieling, W., Axelrod, F. B., Benditt, D. G., Benarroch, E., Biaggioni, I., Cheshire, W. P., Chelimsky, T., Cortelli, P., Gibbons, C. H., Goldstein, D. S., Hainsworth, R., Hilz, M. J., Jacob, G., Kaufmann, H., Jordan, J., Lipsitz, L. A., Levine, B. D., Low, P. A., ... van Dijk, J. G. (2011). Consensus statement on the definition of orthostatic hypotension, neurally mediated syncope and the postural tachycardia syndrome. Clinical Autonomic Research, 21(2), 69–72. https://doi.org/10.1007/s10286-011-0119-5
  2. Gibbons, C. H., Schmidt, P., Biaggioni, I., Frazier-Mills, C., Freeman, R., Isaacson, S., Karabin, B., Kuritzky, L., Lew, M., Low, P., Mehdirad, A., Raj, S. R., Vernino, S., Kaufmann, H., & Shibao, C. A. (2017). The recommendations of a consensus panel for the screening, diagnosis, and treatment of neurogenic orthostatic hypotension and associated supine hypertension. Journal of Neurology, 264(8), 1567–1582. https://doi.org/10.1007/s00415-016-8375-x
  3. Eschlböck, S., Wenning, G., & Fanciulli, A. (2017). Evidence-based treatment of neurogenic orthostatic hypotension and related symptoms. Journal of Neural Transmission, 124(12), 1567–1605. https://doi.org/10.1007/s00702-017-1791-y
  4. Palma, J. A., & Kaufmann, H. (2020). Management of orthostatic hypotension. Continuum: Lifelong Learning in Neurology, 26(1), 154–177. https://doi.org/10.1212/CON.0000000000000816
  5. Kim, M. J., Farrell, J., & Ellenbogen, M. I. (2022). Orthostatic hypotension: A practical approach. American Family Physician, 105(1), 39–49.
  6. Hauser, R. A., Heritier, S., Rowse, G. J., Hewitt, L. A., & Isaacson, S. H. (2015). Droxidopa and reduced falls in a trial of Parkinson disease patients with neurogenic orthostatic hypotension. Clinical Neuropharmacology, 39(5), 220–226. https://doi.org/10.1097/WNF.0000000000000158