How to treat orthostatic hypotension?

The treatment of orthostatic hypotention (OH) can be challenging as the ultimate goal is to improve blood pressure upon standing, but this must be accomplished without excessively increasing blood pressure when lying down (supine hypertension). Supine hypertension is of particular concern in individuals with NOH.

Specific therapies depend upon the underlying cause. When OH is caused by a decrease in volume of circulating blood (hypovolemia) due to the use of certain medication(s), it is treated by adjusting the dosage or discontinuing the medication, under a doctor’s supervision. Hypovolemia also responds to an increase in salt intake. Low blood pressure resulting from extended bed rest can be corrected by allowing the affected individual to sit up each day at certain times with increasing frequency.

Some relief particularly in mild cases may be achieved by taking some simple precautions such as avoiding hot baths that lower blood pressure, avoiding long walks in hot weather, and taking medications that help raise blood pressure, strengthen bladder tone, or prevent constipation. Taking one’s time when changing positions including rising from a chair or getting up from bed can help. Elevating the head of the bed may be of benefit in some cases. Limiting alcohol intake and avoiding large carbohydrate-laden meals can help in specific cases. Exercise programs geared toward improving conditioning and strengthening the legs can be of benefit. These programs may also teach specific physical maneuvers designed to avoid OH such as toe raises, thigh contractions, leg crossing, and bending over at the waist.

Maintaining an elevated salt-intake may be prescribed, either through sodium supplements or drinks containing electrolytes. Drinking a large quantity of fluids also can aid in preventing OH episodes by preventing dehydration. Increasing fluid and salt intake are essential to help to expand blood volume. Water boluses, which involve drinking glasses of water in rapid succession, can help to expand blood volume. The specific amount reported in the medical literature varies, but is approximately two 8 ounce glasses of water.

In some cases, the legs may be fitted for elastic stocking that can help maintain blood pressure upon standing. A medical compression garment known as an abdominal binder used alone or in combination with elastic, compression stockings may provide relief of OH.

In 1996, the drug midodrine hydrochloride (ProAmatine®) was approved by the U.S. Food and Drug Administration (FDA) to treat OH by reducing the radius of blood vessels and thus, increasing blood pressure. In 2011, the FDA requested additional clinical trials to assess the efficacy of midodrine in individuals with OH.

In February of 2014, the FDA approved droxidopa (Northera®) for the treatment of adults with NOH caused by Parkinson’s disease, multiple system atrophy, pure autonomic failure, dopamine beta-hydroxylase deficiency and non-diabetic autonomic neuropathy. Northera was approved under the FDA’s accelerated approval program and has demonstrated short-term relief from the symptoms of NOH. The continued safety and effectiveness of this drug is continually being assessed.

Other medications have been used off label to treat individuals with OH including pyridostigmine. This drug acts on the sympathetic baroreflex pathway, which is active during standing. The drug can improve OH without worsening or aggravating supine hypertension. However, the effects of pyridostigmine are mild and the drug is generally used for individuals with mild cases of OH. In more severe cases, fludrocortisone (Florinef®) may be used. This drug increases blood volume and enhances the response of blood vessels to catecholamines such as norepinephrine.

Additional medications have shown some benefit in treating OH including non-steroidal anti-inflammatories (NSAIDs), caffeine, and erythropoietin. These drugs may be given alone on in combination.

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