Therapeutic Advances in the Management of Orthostatic Hypotension

Background: Orthostatic hypotension (OH) is a common condition in hospitalized geriatric patients. These patients are more susceptible to OH during dehydration and volume depletion. Areas of Uncertainty: OH is often times asymptomatic. There is clear evidence that OH is a risk factor for cardiovascular disease, ischemic stroke, and mortality. Although certain treatments have demonstrated some success in improving OH, it is unclear whether these interventions have any effect on clinical outcomes such as falls, syncope, and mortality. Therapeutic Advances: Initial approaches to treatment should focus on nonpharmaceutical interventions, such as education about symptom recognition, lifestyle modifications, promotion of early mobilization, and avoidance of unnecessary bed rest orders. Pharmaceutical treatments are only indicated if the patient continues to be symptomatic in spite on nonpharmacologic interventions. The 2 main approaches to treating hypotension with pharmaceuticals include increasing blood volume and peripheral vascular resistance. Fludrocortisone should not be used as an isolated therapy, but a next step after dietary salt and water expansion. The recommended starting dose of fludrocortisone is 0.1 mg daily early in the morning with potential weekly increase up to 0.3 mg per day. If fludrocortisone is unsuccessful, midodrine may be used to increase peripheral vascular resistance. The starting dose of midodrine is 2.5 mg 3 times per day, with a slow titration to a maximum of 10 mg 3 times per day. Given the increased potential for underlying cardiovascular diseases in geriatric patients, midodrine should be used cautiously in acute illness. The use of prostaglandin inhibitors that is nonsteroidal anti-inflammatory drugs to raise blood pressure should be limited because of the increased risk of gastrointestinal bleeding, renal failure, and electrolytes abnormalities in elderly adults. Other agents which may be of benefit include clonidine, yohimbine, pyridostigmine, methylxanthine, dihydroergotamine, Cafergot, octreotide, and droxidopa; however, their use is conditional to certain etiologies behind OH, and the supporting evidence is low. Conclusions: Although there is no accepted protocol regarding how to manage hypertension in patients with OH, some studies favor the use of beta blockers and angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, over alpha-receptor antagonists and diuretics.