The treatment plan for orthostatic hypotension (OH) involves a combination of non-pharmacological and pharmacological interventions, tailored to the individual patient's needs and the underlying cause of the condition.
Initial evaluation
- The initial evaluation of patients with suspected OH should include structured history taking, detailed physical examination, supine and upright blood pressure (BP) measurements, 12-lead ECG recording, and active standing or head-up tilt test, ideally with continuous assessment of BP and heart rate for 3 minutes
- Further autonomic nervous system screening tests, along with other appropriate investigations, may be necessary depending on the possible etiology of the underlying disorder
Non-pharmacological interventions
- Non-pharmacological interventions are primarily recommended and include physical and nutritional measures
- Physical measures that may improve OH include leg crossing, squatting, elastic abdominal binders and stockings, and careful exercise
- Increased water (2–2.5 L/day) and salt ingestion (>8 g or 150 mmol/day) effectively improve OH
- Lower-body physical counterpressure maneuvers such as leg crossing and tensing or squatting are preferable to upper-body and abdominal physical counterpressure maneuvers
Pharmacological interventions
- Pharmacological interventions are considered in selected cases and include medications such as midodrine, fludrocortisone, and domperidone
- Midodrine is recommended as a first-line treatment, either alone or combined with fludrocortisone. The last dose of midodrine should be administered at least 4 hours before going to sleep, and monitoring for the development of supine hypertension is necessary
- Fludrocortisone is also recommended as a first-line drug monotherapy for OH. Patients are advised to maintain a high dietary salt and adequate fluid intake to obtain full benefits from fludrocortisone treatment
- Pre-prandial octreotide (25–50 mcg subcutaneous, 30 minutes before meals) can be considered to reduce post-prandial OH
Specific circumstances
- In patients with efferent autonomic failure and symptomatic OH, initial non-pharmacological treatments such as increased sodium ingestion, sufficient water ingestion, and venous compression garments are recommended. Medications that worsen OH (such as diuretics, α-1 blockers, and vasodilators) should be discontinued whenever possible
In conclusion, the treatment plan for OH is individualized and primarily non-pharmacological, with pharmacological interventions considered in selected cases. The goal is to improve the patient's quality of life by managing symptoms and preventing complications