Materiały źródłowe

• #1 Evaluation and Management of Orthostatic Hypotension | AAFP

  https://www.aafp.org/pubs/afp/issues/2011/0901/p527.html

  Orthostatic hypotension is defined as a decrease in systolic blood pressure of 20 mm Hg or a decrease in diastolic blood pressure of 10 mm Hg within three minutes of standing when compared with blood pressure from the sitting or supine position. It results from an inadequate physiologic response to postural changes in blood pressure. […] Goals of treatment involve improving hypotension without excessive supine hypertension, relieving orthostatic symptoms, and improving standing time. Treatment includes correcting reversible causes and discontinuing responsible medications, when possible. Nonpharmacologic treatment should be offered to all patients. For patients who do not respond adequately to nonpharmacologic treatment, fludrocortisone, midodrine, and pyridostigmine are pharmacologic therapies proven to be beneficial.

• #2 Orthostatic Hypotension: A Practical Approach | AAFP

  https://www.aafp.org/pubs/afp/issues/2022/0100/p39.html

  Orthostatic hypotension is defined as a decrease in blood pressure of 20 mm Hg or more systolic or 10 mm Hg or more diastolic within three minutes of standing from the supine position or on assuming a head-up position of 60 degrees during tilt table testing. Symptoms are due to inadequate physiologic compensation and organ hypoperfusion and include headache, lightheadedness, shoulder and neck pain (coat hanger syndrome), visual disturbances, dyspnea, and chest pain. […] Treatment goals for orthostatic hypotension are reducing symptoms and improving quality of life. Initial treatment focuses on the underlying cause and adjusting potentially causative medications. Nonpharmacologic strategies include dietary modifications, compression garments, physical maneuvers, and avoiding environments that exacerbate symptoms. First-line medications include midodrine and droxidopa. Although fludrocortisone improves symptoms, it has concerning long-term effects.

• #3 Preventing and treating orthostatic hypotension: As easy as A, B, C

  https://pmc.ncbi.nlm.nih.gov/articles/PMC2888469/

  Orthostatic hypotension is a chronic, debilitating illness that is difficult to treat. The therapeutic goal is to improve postural symptoms, standing time, and function rather than to achieve upright normotension, which can lead to supine hypertension. Drug therapy alone is never adequate. […] Treatment can be challenging, especially if the problem is neurogenic. This condition has no cure, symptoms vary in different circumstances, treatment is nonspecific, and aggressive treatment can lead to marked supine hypertension. […] The goal of management of orthostatic hypotension is to raise the patients standing blood pressure without also raising his or her supine blood pressure, and specifically to reduce orthostatic symptoms, increase the time the patient can stand, and improve his or her ability to perform daily activities. No specific treatment is currently available that achieves all these goals, and drugs alone are never completely adequate.

• #4 Orthostatic Hypotension: A Practical Approach | AAFP

  https://www.aafp.org/pubs/afp/issues/2022/0100/p39.html

  Orthostatic hypotension is defined as a decrease in blood pressure of 20 mm Hg or more systolic or 10 mm Hg or more diastolic within three minutes of standing from the supine position or on assuming a head-up position of 60 degrees during tilt table testing. Symptoms are due to inadequate physiologic compensation and organ hypoperfusion and include headache, lightheadedness, shoulder and neck pain (coat hanger syndrome), visual disturbances, dyspnea, and chest pain. […] Treatment goals for orthostatic hypotension are reducing symptoms and improving quality of life. Initial treatment focuses on the underlying cause and adjusting potentially causative medications. Nonpharmacologic strategies include dietary modifications, compression garments, physical maneuvers, and avoiding environments that exacerbate symptoms. First-line medications include midodrine and droxidopa. Although fludrocortisone improves symptoms, it has concerning long-term effects.

• #5 Orthostatic hypotension (postural hypotension) – Diagnosis & treatment – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/orthostatic-hypotension/diagnosis-treatment/drc-20352553

  A health care provider’s goal in evaluating orthostatic hypotension is to find the cause and determine treatment. The cause isn’t always known. […] Treatment for orthostatic hypotension is directed at the cause rather than the low blood pressure itself. For example, if dehydration causes orthostatic hypotension, your health care provider may suggest lifestyle changes such as drinking more water. If a medication causes low blood pressure when standing, treatment may involve changing the dose or stopping the drug. […] If orthostatic hypotension doesn’t improve with lifestyle changes, medications may be needed to increase blood pressure or blood volume. The type of medication depends on the type of orthostatic hypotension. […] Drugs that may be used to treat orthostatic hypotension include midodrine (Orvaten), droxidopa (Northera), fludrocortisone or pyridostigmine (Mestinon, Regonol).

• #6 Preventing and treating orthostatic hypotension: As easy as A, B, C

  https://pmc.ncbi.nlm.nih.gov/articles/PMC2888469/

  Orthostatic hypotension is a chronic, debilitating illness that is difficult to treat. The therapeutic goal is to improve postural symptoms, standing time, and function rather than to achieve upright normotension, which can lead to supine hypertension. Drug therapy alone is never adequate. […] Treatment can be challenging, especially if the problem is neurogenic. This condition has no cure, symptoms vary in different circumstances, treatment is nonspecific, and aggressive treatment can lead to marked supine hypertension. […] The goal of management of orthostatic hypotension is to raise the patients standing blood pressure without also raising his or her supine blood pressure, and specifically to reduce orthostatic symptoms, increase the time the patient can stand, and improve his or her ability to perform daily activities. No specific treatment is currently available that achieves all these goals, and drugs alone are never completely adequate.

• #7 Preventing and treating orthostatic hypotension: As easy as A, B, C | MDedge

  https://www.mdedge.com/content/preventing-and-treating-orthostatic-hypotension-easy-b-c

  Orthostatic hypotension is a chronic, debilitating illness that is difficult to treat. The therapeutic goal is to improve postural symptoms, standing time, and function rather than to achieve upright normotension, which can lead to supine hypertension. Drug therapy alone is never adequate. Because orthostatic stress varies with circumstances during the day, a patient-oriented approach that emphasizes education and nonpharmacologic strategies is critical. We provide easy-to-remember management recommendations, using a combination of drug and nondrug treatments that have proven efficacious. […] Treatment is directed at increasing blood volume, decreasing venous pooling, and increasing vasoconstriction while minimizing supine hypertension. […] Patient education and nondrug strategies alone can be effective in mild cases. Examples: consuming extra fluids and salt, wearing an abdominal binder, drinking boluses of water, raising the head of the bed, and performing countermaneuvers and physical activity.

• #8 Evaluation and Management of Orthostatic Hypotension | AAFP

  https://www.aafp.org/pubs/afp/issues/2011/0901/p527.html

  Nonpharmacologic treatment should be offered to all patients initially. If potentially contributing medications cannot be discontinued, then patients should be instructed to take them at bedtime when possible, particularly antihypertensives. Patients should avoid large carbohydrate-rich meals (to prevent postprandial hypotension), limit alcohol intake, and ensure adequate hydration. […] In patients who do not respond adequately to nonpharmacologic therapy for orthostatic hypotension, medication may be indicated. Fludrocortisone, which is a synthetic mineralocorticoid, is considered first-line therapy for the treatment of orthostatic hypotension. […] Midodrine, a peripheral selective alpha-1-adrenergic agonist, significantly increases standing systolic blood pressure and improves symptoms in patients with neurogenic orthostatic hypotension. […] Pyridostigmine is a cholinesterase inhibitor that improves neurotransmission at acetylcholine-mediated neurons of the autonomic nervous system.

• #9 Management of Orthostatic Hypotension

  https://pmc.ncbi.nlm.nih.gov/articles/PMC7339914/

  Correction of aggravating factors can increase blood pressure sufficiently to improve orthostatic tolerance in some patients and should be the first step in the management of neurogenic orthostatic hypotension. […] Nonpharmacologic treatments for orthostatic hypotension are listed in TABLE 9-2. […] The initial treatment of orthostatic hypotension focuses on nonpharmacologic measures first: removing offending medications, increasing salt and fluid intake, using compression garments, and instituting physical maneuvers and exercise. […] Despite removal of aggravating factors and implementing nonpharmacologic methods, many patients remain symptomatic and require pharmacologic treatment. […] Current pharmacologic approaches are based on two complementary strategies: (1) expanding intravascular volume with fludrocortisone and (2) increasing peripheral vascular resistance with midodrine, droxidopa, or norepinephrine reuptake inhibitors.

• #10 Orthostatic hypotension (postural hypotension) – Diagnosis & treatment – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/orthostatic-hypotension/diagnosis-treatment/drc-20352553

  Some simple steps can help manage or prevent orthostatic hypotension. These include: […] Getting plenty of fluids. Keeping hydrated helps prevent symptoms of low blood pressure. Drink plenty of water before long periods of standing, or any activities that tend to trigger symptoms. […] Avoiding alcohol. Alcohol can worsen orthostatic hypotension, so limit or avoid it completely. […] Increasing salt in the diet. This must be done carefully and only after discussing it with a health care provider. Too much salt can cause blood pressure to increase beyond a healthy level, creating new health risks. […] For orthostatic hypotension, questions to ask your health care provider include: What’s the most appropriate treatment?

• #11 Diagnosis and management of neurogenic orthostatic hypotension

  https://www.e-acn.org/journal/view.php?number=643

  Experts suggest a 4-step treatment algorithm: a review of the patients medications, non-pharmacologic measures, initiation of a single pharmacologic agent, and combination pharmacologic agents. […] When feasible, factors that can aggravate OH should be corrected. […] If OH symptoms persist and affect daily activities after correction of the precipitating factors, non-pharmacological measures need to be considered. […] Physical counter-maneuvers such as squatting, leg-crossing, thigh contraction, and bending at the waist can reduce venous pooling and increase total peripheral resistance quickly through mechanical compression of the vein. […] An increase in water and salt intake may expand the intravascular volume and reduce the severity of OH. […] To expand circulating fluid, water intake needs to increase up to 2-2.5 L of water per day.

• #12 Orthostatic hypotension (postural hypotension) – Diagnosis & treatment – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/orthostatic-hypotension/diagnosis-treatment/drc-20352553

  Some simple steps can help manage or prevent orthostatic hypotension. These include: […] Getting plenty of fluids. Keeping hydrated helps prevent symptoms of low blood pressure. Drink plenty of water before long periods of standing, or any activities that tend to trigger symptoms. […] Avoiding alcohol. Alcohol can worsen orthostatic hypotension, so limit or avoid it completely. […] Increasing salt in the diet. This must be done carefully and only after discussing it with a health care provider. Too much salt can cause blood pressure to increase beyond a healthy level, creating new health risks. […] For orthostatic hypotension, questions to ask your health care provider include: What’s the most appropriate treatment?

• #13 Orthostatic hypotension (postural hypotension) – Hancock Health

  https://www.hancockhealth.org/mayo-health-library/orthostatic-hypotension-postural-hypotension/

  If orthostatic hypotension doesnt improve with lifestyle changes, medications may be needed to increase blood pressure or blood volume. The type of medication depends on the type of orthostatic hypotension. […] Drugs that may be used to treat orthostatic hypotension include midodrine (Orvaten), droxidopa (Northera), fludrocortisone or pyridostigmine (Mestinon, Regonol). […] Some simple steps can help manage or prevent orthostatic hypotension. These include: Wearing waist-high compression stockings. These may help improve blood flow and reduce the symptoms of orthostatic hypotension. […] Getting plenty of fluids. Keeping hydrated helps prevent symptoms of low blood pressure. […] Avoiding alcohol. Alcohol can worsen orthostatic hypotension, so limit or avoid it completely. […] Increasing salt in the diet. This must be done carefully and only after discussing it with a health care provider.

• #14 Orthostatic hypotension (postural hypotension) – Diagnosis & treatment – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/orthostatic-hypotension/diagnosis-treatment/drc-20352553

  Some simple steps can help manage or prevent orthostatic hypotension. These include: […] Getting plenty of fluids. Keeping hydrated helps prevent symptoms of low blood pressure. Drink plenty of water before long periods of standing, or any activities that tend to trigger symptoms. […] Avoiding alcohol. Alcohol can worsen orthostatic hypotension, so limit or avoid it completely. […] Increasing salt in the diet. This must be done carefully and only after discussing it with a health care provider. Too much salt can cause blood pressure to increase beyond a healthy level, creating new health risks. […] For orthostatic hypotension, questions to ask your health care provider include: What’s the most appropriate treatment?

• #15 Evaluation and Management of Orthostatic Hypotension | AAFP

  https://www.aafp.org/pubs/afp/issues/2011/0901/p527.html

  Nonpharmacologic treatment should be offered to all patients initially. If potentially contributing medications cannot be discontinued, then patients should be instructed to take them at bedtime when possible, particularly antihypertensives. Patients should avoid large carbohydrate-rich meals (to prevent postprandial hypotension), limit alcohol intake, and ensure adequate hydration. […] In patients who do not respond adequately to nonpharmacologic therapy for orthostatic hypotension, medication may be indicated. Fludrocortisone, which is a synthetic mineralocorticoid, is considered first-line therapy for the treatment of orthostatic hypotension. […] Midodrine, a peripheral selective alpha-1-adrenergic agonist, significantly increases standing systolic blood pressure and improves symptoms in patients with neurogenic orthostatic hypotension. […] Pyridostigmine is a cholinesterase inhibitor that improves neurotransmission at acetylcholine-mediated neurons of the autonomic nervous system.

• #16 Orthostatic hypotension (postural hypotension) – Hancock Health

  https://www.hancockhealth.org/mayo-health-library/orthostatic-hypotension-postural-hypotension/

  Eating small meals. If blood pressure drops after eating, having small, low-carbohydrate meals might help. […] Exercising. Regular cardiovascular and strengthening exercises might help reduce symptoms of orthostatic hypotension. […] Getting up slowly. Move slowly from a lying to standing position. […] Raising the head of the bed. Sleeping with the head of the bed slightly raised can help fight the effects of gravity.

• #17 Orthostatic hypotension (postural hypotension) – Hancock Health

  https://www.hancockhealth.org/mayo-health-library/orthostatic-hypotension-postural-hypotension/

  If orthostatic hypotension doesnt improve with lifestyle changes, medications may be needed to increase blood pressure or blood volume. The type of medication depends on the type of orthostatic hypotension. […] Drugs that may be used to treat orthostatic hypotension include midodrine (Orvaten), droxidopa (Northera), fludrocortisone or pyridostigmine (Mestinon, Regonol). […] Some simple steps can help manage or prevent orthostatic hypotension. These include: Wearing waist-high compression stockings. These may help improve blood flow and reduce the symptoms of orthostatic hypotension. […] Getting plenty of fluids. Keeping hydrated helps prevent symptoms of low blood pressure. […] Avoiding alcohol. Alcohol can worsen orthostatic hypotension, so limit or avoid it completely. […] Increasing salt in the diet. This must be done carefully and only after discussing it with a health care provider.

• #18 Orthostatic hypotension (postural hypotension) | Beacon Health System

  https://www.beaconhealthsystem.org/library/diseases-and-conditions/orthostatic-hypotension-postural-hypotension?content_id=CON-20303971

  Eating small meals. If blood pressure drops after eating, having small, low-carbohydrate meals might help. […] Exercising. Regular cardiovascular and strengthening exercises might help reduce symptoms of orthostatic hypotension. Avoid exercising in very hot, humid weather. […] Moving and stretching in certain ways. Stretch and flex calf muscles before sitting up. For symptoms, squeeze thighs together and squeeze stomach and buttock muscles. Squat, march in place or rise onto tiptoes. […] Getting up slowly. Move slowly from a lying to standing position. Also, when getting out of bed, sit on the edge of the bed for a minute before standing. […] Raising the head of the bed. Sleeping with the head of the bed slightly raised can help fight the effects of gravity.

• #19 Diagnosis and management of neurogenic orthostatic hypotension

  https://www.e-acn.org/journal/view.php?number=643

  Experts suggest a 4-step treatment algorithm: a review of the patients medications, non-pharmacologic measures, initiation of a single pharmacologic agent, and combination pharmacologic agents. […] When feasible, factors that can aggravate OH should be corrected. […] If OH symptoms persist and affect daily activities after correction of the precipitating factors, non-pharmacological measures need to be considered. […] Physical counter-maneuvers such as squatting, leg-crossing, thigh contraction, and bending at the waist can reduce venous pooling and increase total peripheral resistance quickly through mechanical compression of the vein. […] An increase in water and salt intake may expand the intravascular volume and reduce the severity of OH. […] To expand circulating fluid, water intake needs to increase up to 2-2.5 L of water per day.

• #20 Management of Orthostatic Hypotension

  https://pmc.ncbi.nlm.nih.gov/articles/PMC7339914/

  Fludrocortisone is a synthetic mineralocorticoid that increases renal sodium and water reabsorption, therefore expanding intravascular volume and increasing blood pressure in all positions. […] Midodrine is an oral prodrug converted peripherally into the active metabolite desglymidodrine, a selective 1-adrenoceptor agonist that constricts arteriolar and venous vasculature, thus increasing blood pressure. […] Droxidopa is an oral synthetic amino acid that converts to norepinephrine. […] An emerging approach in the treatment of neurogenic orthostatic hypotension is the use of inhibitors of the norepinephrine membrane transporter, which inhibit norepinephrine reuptake and increase its availability in the neurovascular junction. […] Treatment of postprandial hypotension includes reducing high glycemic index carbohydrates, eating smaller and more frequent meals, and using the -glucosidase inhibitor acarbose. […] Neurogenic supine hypertension is best treated with postural measures, ie, avoiding the flat position and sleeping with the head of the bed raised 30 to 45 degrees with the help of an electric bed or mattress.

• #21 Orthostatic hypotension (postural hypotension) – Hancock Health

  https://www.hancockhealth.org/mayo-health-library/orthostatic-hypotension-postural-hypotension/

  Eating small meals. If blood pressure drops after eating, having small, low-carbohydrate meals might help. […] Exercising. Regular cardiovascular and strengthening exercises might help reduce symptoms of orthostatic hypotension. […] Getting up slowly. Move slowly from a lying to standing position. […] Raising the head of the bed. Sleeping with the head of the bed slightly raised can help fight the effects of gravity.

• #22 Orthostatic Hypotension – Cardiovascular Disorders – Merck Manual Professional Edition

  https://www.merckmanuals.com/professional/cardiovascular-disorders/symptoms-of-cardiovascular-disorders/orthostatic-hypotension

  Orthostatic hypotension occurs in approximately 15 to 20% of older adults (1). […] Treatment involves physical measures to reduce venous pooling, increased sodium intake, and sometimes fludrocortisone or midodrine. […] Patients requiring prolonged bed rest should sit up each day and exercise in bed when possible. Patients should rise slowly from a recumbent or sitting position, consume adequate fluids, limit or avoid alcohol, and exercise regularly when feasible. Regular modest-intensity exercise promotes overall vascular tone and reduces venous pooling. […] Fludrocortisone, a mineralocorticoid, causes sodium retention, which expands plasma volume, and often lessens symptoms but is effective only when sodium intake is adequate. […] Midodrine, a peripheral alpha-agonist that is both an arterial and a venous constrictor, is often effective. […] Nonsteroidal anti-inflammatory drugs (NSAIDs, eg, indomethacin 25 to 50 mg orally 3 times a day) may inhibit prostaglandin-induced vasodilation, increasing peripheral vascular resistance. […] Pyridostigmine and octreotide have been effective in small clinical studies.

• #23 Orthostatic Hypotension | CardioVascular Health Clinicsearchenvelope-oexclamation-circlechevron-downlinkedin-squarephonefacebookuser-mdinstagramcrossmenu

  https://cvhealthclinic.com/conditions-treated/orthostatic-hypotension/

  Getting regular exercise. Physical fitness is a highly effective management tool for orthostatic hypotension and can mitigate symptoms. However, do not exercise in extreme heat. […] Standing up slowly. If you feel faint when standing suddenly after lying down, take a moment, breathe deeply, and rise slowly.

• #24 Diagnosis and management of neurogenic orthostatic hypotension

  https://www.e-acn.org/journal/view.php?number=643

  Compressive garments for OH include custom-fitted elastic stockings (e.g., waist-high, thigh-high) and abdominal binder. […] Activities such as prolonged standing, alcohol consumption, hot showers, and saunas should be avoided as they augment vasodilation and venous pooling. […] If non-pharmacological treatments are not sufficient, pharmacological treatments can be used in combination. […] There are two categories of medications: NE enhancers and replacers. […] Midodrine is the most used medication for OH due to its availability, minimal drug interaction, and quick onset with predictable effects. […] Fludrocortisone, which is a synthetic mineralocorticoid analog, potentiates 1 receptor activity and expands plasma volume through the urinary reabsorption of water and salt. […] Droxidopa is an oral synthetic amino acid that provides exogenous NE, as it is converted to NE through decarboxylation. […] Pyridostigmine is a reversible cholinesterase inhibitor that potentiates cholinergic neurotransmission in the autonomic ganglia, both sympathetic and parasympathetic. […] A stepwise approach is recommended to manage N-OH symptoms.

• #25 Orthostatic hypotension (postural hypotension) – Augusta HealthSearchClose SearchSearch IconSearch IconClose Search IconMobile Menu IconMobile Menu Close IconInstagramFacebookTwitterYoutube

  https://www.augustahealth.com/disease/orthostatic-hypotension-postural-hypotension/

  Orthostatic hypotension treatments include: […] Lifestyle changes. Your doctor may suggest several lifestyle changes, including drinking enough water; drinking little to no alcohol; avoiding overheating; elevating the head of your bed; avoiding crossing your legs when sitting; and standing up slowly. […] Compression stockings. Compression stockings and garments or abdominal binders may help reduce the pooling of blood in your legs and reduce the symptoms of orthostatic hypotension. […] Medications. A few drugs are used to treat orthostatic hypotension, including midodrine (Orvaten) and droxidopa (Northera). […] Fludrocortisone is often used to help increase the amount of fluid in your blood, which raises blood pressure, but it can have serious side effects. […] Another medication is pyridostigmine (Mestinon, Regonol). This drug might be more effective combined with midodrine.

• #26 Diagnosis and management of neurogenic orthostatic hypotension

  https://www.e-acn.org/journal/view.php?number=643

  Compressive garments for OH include custom-fitted elastic stockings (e.g., waist-high, thigh-high) and abdominal binder. […] Activities such as prolonged standing, alcohol consumption, hot showers, and saunas should be avoided as they augment vasodilation and venous pooling. […] If non-pharmacological treatments are not sufficient, pharmacological treatments can be used in combination. […] There are two categories of medications: NE enhancers and replacers. […] Midodrine is the most used medication for OH due to its availability, minimal drug interaction, and quick onset with predictable effects. […] Fludrocortisone, which is a synthetic mineralocorticoid analog, potentiates 1 receptor activity and expands plasma volume through the urinary reabsorption of water and salt. […] Droxidopa is an oral synthetic amino acid that provides exogenous NE, as it is converted to NE through decarboxylation. […] Pyridostigmine is a reversible cholinesterase inhibitor that potentiates cholinergic neurotransmission in the autonomic ganglia, both sympathetic and parasympathetic. […] A stepwise approach is recommended to manage N-OH symptoms.

• #27 Evaluation and management of orthostatic hypotension: Limited data, limitless opportunity | Cleveland Clinic Journal of Medicine

  https://www.ccjm.org/content/89/1/36

  Most causes of OH requiring long-term treatment are neurogenic. A consensus panel assembled by the American Autonomic Society and the National Parkinson Foundation recommends a stepwise approach to the treatment of neurogenic OH. […] Step 1 is a detailed medication review to identify drugs that often cause OH. Long-acting antihypertensives almost always should be stopped. […] Step 2 is the addition of nonpharmacologic measures. Exercise increases muscle tone and improves venomotor competence, reducing venous pooling, but should be either recumbent (eg, on a recumbent bike or rowing machine) or aquatic (swimming or pool-walking) to maximize tolerability. […] I recommend high sodium (150 mEq/day) and fluid (at least 2 L/day) intake to most patients. […] Step 3 is drug treatment. Despite the absence of high-quality evidence to support their use, the cornerstone drugs are fludrocortisone, midodrine, and droxidopa; pyridostigmine and atomoxetine are used less often.

• #28 Evaluation and management of orthostatic hypotension: Limited data, limitless opportunity | Cleveland Clinic Journal of Medicine

  https://www.ccjm.org/content/89/1/36

  Most causes of OH requiring long-term treatment are neurogenic. A consensus panel assembled by the American Autonomic Society and the National Parkinson Foundation recommends a stepwise approach to the treatment of neurogenic OH. […] Step 1 is a detailed medication review to identify drugs that often cause OH. Long-acting antihypertensives almost always should be stopped. […] Step 2 is the addition of nonpharmacologic measures. Exercise increases muscle tone and improves venomotor competence, reducing venous pooling, but should be either recumbent (eg, on a recumbent bike or rowing machine) or aquatic (swimming or pool-walking) to maximize tolerability. […] I recommend high sodium (150 mEq/day) and fluid (at least 2 L/day) intake to most patients. […] Step 3 is drug treatment. Despite the absence of high-quality evidence to support their use, the cornerstone drugs are fludrocortisone, midodrine, and droxidopa; pyridostigmine and atomoxetine are used less often.

• #29 Diagnosis and management of neurogenic orthostatic hypotension

  https://www.e-acn.org/journal/view.php?number=643

  Compressive garments for OH include custom-fitted elastic stockings (e.g., waist-high, thigh-high) and abdominal binder. […] Activities such as prolonged standing, alcohol consumption, hot showers, and saunas should be avoided as they augment vasodilation and venous pooling. […] If non-pharmacological treatments are not sufficient, pharmacological treatments can be used in combination. […] There are two categories of medications: NE enhancers and replacers. […] Midodrine is the most used medication for OH due to its availability, minimal drug interaction, and quick onset with predictable effects. […] Fludrocortisone, which is a synthetic mineralocorticoid analog, potentiates 1 receptor activity and expands plasma volume through the urinary reabsorption of water and salt. […] Droxidopa is an oral synthetic amino acid that provides exogenous NE, as it is converted to NE through decarboxylation. […] Pyridostigmine is a reversible cholinesterase inhibitor that potentiates cholinergic neurotransmission in the autonomic ganglia, both sympathetic and parasympathetic. […] A stepwise approach is recommended to manage N-OH symptoms.

• #30 Orthostatic Hypotension: A Practical Approach | AAFP

  https://www.aafp.org/pubs/afp/issues/2022/0100/p39.html

  Treatment of orthostatic hypotension should be aimed at reducing symptoms to improve quality of life, rather than normalizing blood pressure. Nonpharmacologic management strategies should be attempted before prescribing a medication. If nonpharmacologic management is insufficient alone, it should be used in combination with medications. […] First-line pharmacologic therapy should include midodrine or droxidopa (Northera) titrated to relieve symptoms. […] Midodrine, a short-acting alpha-1 adrenergic agonist that acts via vasoconstriction, has been shown to alleviate symptoms of orthostatic hypotension and elevate blood pressure in multiple randomized placebo-controlled trials. […] Droxidopa, a short-acting norepinephrine precursor, is another first-line medication approved by the U.S. Food and Drug administration for the treatment of orthostatic hypotension.

• #31 Preventing and treating orthostatic hypotension: As easy as A, B, C

  https://pmc.ncbi.nlm.nih.gov/articles/PMC2888469/

  Therapies primarily consist of a combination of vasoconstrictor drugs, volume expansion, compression garments, and postural adjustment. Education about orthostatic stressors and warning symptoms empowers the patient to adopt easy lifestyle changes to minimize and handle orthostatic stress. […] Midodrine, a vasopressor, is effective and safe when used for treating neurogenic orthostatic hypotension. It has been shown to increase standing systolic blood pressure, reduce orthostatic lightheadedness, and increase standing and walking time. […] Fludrocortisone is a synthetic mineralocorticoid that has a pressor effect as a result of its ability to expand plasma volume and increase vascular alpha-adrenoceptor sensitivity. This medication is helpful when plasma volume fails to adequately increase with salt supplementation and for patients who cannot ingest enough salt or do not respond adequately to midodrine.

• #32 An Overview of Orthostatic Hypotension

  https://www.uspharmacist.com/article/an-overview-of-orthostatic-hypotension

  Midodrine, a peripheral selective direct alpha-1 adrenoreceptor agonist, is the only FDA-approved agent that is specifically indicated for treatment of orthostatic hypotension. […] Fludrocortisone, a synthetic mineralocorticoid, is used as a first-line agent. […] Clonidine, an alpha-2 receptor agonist, is used to treat orthostatic hypotension in patients with severe autonomic dysfunction. […] Pyridostigmine, an acetylcholinesterase inhibitor, may be utilized for the treatment of orthostatic hypotension. […] Combination therapy consisting of midodrine and fludrocortisone, midodrine and pyridostigmine, or midodrine and octreotide has demonstrated increases in blood pressure compared with monotherapy. […] Pharmacists have a role in educating patients about both pharmacologic and nonpharmacologic modalities for controlling and preventing the incidence and consequences of orthostatic hypotension.

• #33 Orthostatic Hypotension: A Practical Approach | AAFP

  https://www.aafp.org/pubs/afp/issues/2022/0100/p39.html

  Treatment of orthostatic hypotension should be aimed at reducing symptoms to improve quality of life, rather than normalizing blood pressure. Nonpharmacologic management strategies should be attempted before prescribing a medication. If nonpharmacologic management is insufficient alone, it should be used in combination with medications. […] First-line pharmacologic therapy should include midodrine or droxidopa (Northera) titrated to relieve symptoms. […] Midodrine, a short-acting alpha-1 adrenergic agonist that acts via vasoconstriction, has been shown to alleviate symptoms of orthostatic hypotension and elevate blood pressure in multiple randomized placebo-controlled trials. […] Droxidopa, a short-acting norepinephrine precursor, is another first-line medication approved by the U.S. Food and Drug administration for the treatment of orthostatic hypotension.

• #34 Orthostatic Hypotension: A Practical Approach | AAFP

  https://www.aafp.org/pubs/afp/issues/2022/0100/p39.html

  Treatment of orthostatic hypotension should be aimed at reducing symptoms to improve quality of life, rather than normalizing blood pressure. Nonpharmacologic management strategies should be attempted before prescribing a medication. If nonpharmacologic management is insufficient alone, it should be used in combination with medications. […] First-line pharmacologic therapy should include midodrine or droxidopa (Northera) titrated to relieve symptoms. […] Midodrine, a short-acting alpha-1 adrenergic agonist that acts via vasoconstriction, has been shown to alleviate symptoms of orthostatic hypotension and elevate blood pressure in multiple randomized placebo-controlled trials. […] Droxidopa, a short-acting norepinephrine precursor, is another first-line medication approved by the U.S. Food and Drug administration for the treatment of orthostatic hypotension.

• #35 Management of Orthostatic Hypotension

  https://pmc.ncbi.nlm.nih.gov/articles/PMC7339914/

  Fludrocortisone is a synthetic mineralocorticoid that increases renal sodium and water reabsorption, therefore expanding intravascular volume and increasing blood pressure in all positions. […] Midodrine is an oral prodrug converted peripherally into the active metabolite desglymidodrine, a selective 1-adrenoceptor agonist that constricts arteriolar and venous vasculature, thus increasing blood pressure. […] Droxidopa is an oral synthetic amino acid that converts to norepinephrine. […] An emerging approach in the treatment of neurogenic orthostatic hypotension is the use of inhibitors of the norepinephrine membrane transporter, which inhibit norepinephrine reuptake and increase its availability in the neurovascular junction. […] Treatment of postprandial hypotension includes reducing high glycemic index carbohydrates, eating smaller and more frequent meals, and using the -glucosidase inhibitor acarbose. […] Neurogenic supine hypertension is best treated with postural measures, ie, avoiding the flat position and sleeping with the head of the bed raised 30 to 45 degrees with the help of an electric bed or mattress.

• #36 Orthostatic Intolerance Treatment & Management: Medical Care, Diet, Activity

  https://emedicine.medscape.com/article/902155-treatment

  Supportive care and treatment of the underlying illness are essential. Thus, in the case of dopamine-beta-hydroxylase (DBH) deficiency, droxidopa, which bypasses the missing enzyme, can provide definitive remediation. […] It may also be the drug of choice for most neurogenic orthostatic hypotension (NOH) since it can provide norepinephrine production through alternative pathways. […] Supportive therapy focuses on decreasing symptomatic OH and syncope. Such therapy would include physical countermaneuvers including compression garments, and dietary changes (increased salt, rapid water drinking). […] Supportive drug therapy often aims to increase blood volume by promoting salt and water retention (fludrocortisone) or by increasing red blood cell mass (recombinant erythropoietin). […] Short-acting pressor drugs such as midodrine or drugs that enhance autonomic activity (atomoxetine, pyridostigmine) are also used.

• #37 Orthostatic Intolerance Treatment & Management: Medical Care, Diet, Activity

  https://emedicine.medscape.com/article/902155-treatment

  Supportive care and treatment of the underlying illness are essential. Thus, in the case of dopamine-beta-hydroxylase (DBH) deficiency, droxidopa, which bypasses the missing enzyme, can provide definitive remediation. […] It may also be the drug of choice for most neurogenic orthostatic hypotension (NOH) since it can provide norepinephrine production through alternative pathways. […] Supportive therapy focuses on decreasing symptomatic OH and syncope. Such therapy would include physical countermaneuvers including compression garments, and dietary changes (increased salt, rapid water drinking). […] Supportive drug therapy often aims to increase blood volume by promoting salt and water retention (fludrocortisone) or by increasing red blood cell mass (recombinant erythropoietin). […] Short-acting pressor drugs such as midodrine or drugs that enhance autonomic activity (atomoxetine, pyridostigmine) are also used.

• #38 Orthostatic Hypotension: A Practical Approach | AAFP

  https://www.aafp.org/pubs/afp/issues/2022/0100/p39.html

  Fludrocortisone is a synthetic mineralocorticoid that promotes renal sodium reabsorption, thereby increasing intravascular volume. Additionally, it increases vascular alpha-adrenergic receptor sensitivity, promoting vasoconstriction. Expert consensus recommends the off-label use of fludrocortisone in the treatment of orthostatic hypotension.

• #39 Preventing and treating orthostatic hypotension: As easy as A, B, C

  https://pmc.ncbi.nlm.nih.gov/articles/PMC2888469/

  Therapies primarily consist of a combination of vasoconstrictor drugs, volume expansion, compression garments, and postural adjustment. Education about orthostatic stressors and warning symptoms empowers the patient to adopt easy lifestyle changes to minimize and handle orthostatic stress. […] Midodrine, a vasopressor, is effective and safe when used for treating neurogenic orthostatic hypotension. It has been shown to increase standing systolic blood pressure, reduce orthostatic lightheadedness, and increase standing and walking time. […] Fludrocortisone is a synthetic mineralocorticoid that has a pressor effect as a result of its ability to expand plasma volume and increase vascular alpha-adrenoceptor sensitivity. This medication is helpful when plasma volume fails to adequately increase with salt supplementation and for patients who cannot ingest enough salt or do not respond adequately to midodrine.

• #40 Management of Orthostatic Hypotension

  https://pmc.ncbi.nlm.nih.gov/articles/PMC7339914/

  Fludrocortisone is a synthetic mineralocorticoid that increases renal sodium and water reabsorption, therefore expanding intravascular volume and increasing blood pressure in all positions. […] Midodrine is an oral prodrug converted peripherally into the active metabolite desglymidodrine, a selective 1-adrenoceptor agonist that constricts arteriolar and venous vasculature, thus increasing blood pressure. […] Droxidopa is an oral synthetic amino acid that converts to norepinephrine. […] An emerging approach in the treatment of neurogenic orthostatic hypotension is the use of inhibitors of the norepinephrine membrane transporter, which inhibit norepinephrine reuptake and increase its availability in the neurovascular junction. […] Treatment of postprandial hypotension includes reducing high glycemic index carbohydrates, eating smaller and more frequent meals, and using the -glucosidase inhibitor acarbose. […] Neurogenic supine hypertension is best treated with postural measures, ie, avoiding the flat position and sleeping with the head of the bed raised 30 to 45 degrees with the help of an electric bed or mattress.

• #41 Orthostatic Hypotension – Cardiovascular Disorders – Merck Manual Professional Edition

  https://www.merckmanuals.com/professional/cardiovascular-disorders/symptoms-of-cardiovascular-disorders/orthostatic-hypotension

  Orthostatic hypotension occurs in approximately 15 to 20% of older adults (1). […] Treatment involves physical measures to reduce venous pooling, increased sodium intake, and sometimes fludrocortisone or midodrine. […] Patients requiring prolonged bed rest should sit up each day and exercise in bed when possible. Patients should rise slowly from a recumbent or sitting position, consume adequate fluids, limit or avoid alcohol, and exercise regularly when feasible. Regular modest-intensity exercise promotes overall vascular tone and reduces venous pooling. […] Fludrocortisone, a mineralocorticoid, causes sodium retention, which expands plasma volume, and often lessens symptoms but is effective only when sodium intake is adequate. […] Midodrine, a peripheral alpha-agonist that is both an arterial and a venous constrictor, is often effective. […] Nonsteroidal anti-inflammatory drugs (NSAIDs, eg, indomethacin 25 to 50 mg orally 3 times a day) may inhibit prostaglandin-induced vasodilation, increasing peripheral vascular resistance. […] Pyridostigmine and octreotide have been effective in small clinical studies.

• #42 Orthostatic Hypotension (Postural Hypotension)

  https://my.clevelandclinic.org/health/diseases/9385-low-blood-pressure-orthostatic-hypotension

  Possible side effects of drugs for orthostatic hypotension include: Numbness. […] Itching. […] Headaches. […] Swelling. […] Low potassium levels. […] Heart failure. […] Orthostatic hypotension symptoms can be unsettling. […] They may even be dangerous if you lose your balance, fall or pass out. […] Symptoms often improve when you change how you move into a standing position. […] Tell your healthcare provider about your symptoms. […] You may need to change your medications to reduce or prevent symptoms. […] In more severe cases, your provider may prescribe medicine to improve blood flow and pressure.

• #43 Management of Orthostatic Hypotension

  https://pmc.ncbi.nlm.nih.gov/articles/PMC7339914/

  This article reviews the management of orthostatic hypotension with emphasis on neurogenic orthostatic hypotension. […] Whereas fludrocortisone has been extensively used as first-line treatment in the past, it is associated with adverse events including renal and cardiac failure and increased risk of all-cause hospitalization. […] Management of orthostatic hypotension is aimed at improving quality of life and reducing symptoms rather than at normalizing blood pressure. Nonpharmacologic measures are the key to success. Pharmacologic options include volume expansion with fludrocortisone and sympathetic enhancement with midodrine, droxidopa, and norepinephrine reuptake inhibitors. […] Patients with asymptomatic neurogenic orthostatic hypotension usually require education and nonpharmacologic measures only.

• #44 Preventing and treating orthostatic hypotension: As easy as A, B, C

  https://pmc.ncbi.nlm.nih.gov/articles/PMC2888469/

  Pyridostigmine is a cholinesterase inhibitor that improves ganglionic neurotransmission in the sympathetic baroreflex pathway. Because this pathway is activated primarily during standing, this drug improves orthostatic hypotension and total peripheral resistance without aggravating supine hypertension.

• #45 Evaluation and Management of Orthostatic Hypotension | AAFP

  https://www.aafp.org/pubs/afp/issues/2011/0901/p527.html

  Nonpharmacologic treatment should be offered to all patients initially. If potentially contributing medications cannot be discontinued, then patients should be instructed to take them at bedtime when possible, particularly antihypertensives. Patients should avoid large carbohydrate-rich meals (to prevent postprandial hypotension), limit alcohol intake, and ensure adequate hydration. […] In patients who do not respond adequately to nonpharmacologic therapy for orthostatic hypotension, medication may be indicated. Fludrocortisone, which is a synthetic mineralocorticoid, is considered first-line therapy for the treatment of orthostatic hypotension. […] Midodrine, a peripheral selective alpha-1-adrenergic agonist, significantly increases standing systolic blood pressure and improves symptoms in patients with neurogenic orthostatic hypotension. […] Pyridostigmine is a cholinesterase inhibitor that improves neurotransmission at acetylcholine-mediated neurons of the autonomic nervous system.

• #46 Preventing and treating orthostatic hypotension: As easy as A, B, C

  https://pmc.ncbi.nlm.nih.gov/articles/PMC2888469/

  Pyridostigmine is a cholinesterase inhibitor that improves ganglionic neurotransmission in the sympathetic baroreflex pathway. Because this pathway is activated primarily during standing, this drug improves orthostatic hypotension and total peripheral resistance without aggravating supine hypertension.

• #47 Orthostatic hypotension (postural hypotension) – Augusta HealthSearchClose SearchSearch IconSearch IconClose Search IconMobile Menu IconMobile Menu Close IconInstagramFacebookTwitterYoutube

  https://www.augustahealth.com/disease/orthostatic-hypotension-postural-hypotension/

  Orthostatic hypotension treatments include: […] Lifestyle changes. Your doctor may suggest several lifestyle changes, including drinking enough water; drinking little to no alcohol; avoiding overheating; elevating the head of your bed; avoiding crossing your legs when sitting; and standing up slowly. […] Compression stockings. Compression stockings and garments or abdominal binders may help reduce the pooling of blood in your legs and reduce the symptoms of orthostatic hypotension. […] Medications. A few drugs are used to treat orthostatic hypotension, including midodrine (Orvaten) and droxidopa (Northera). […] Fludrocortisone is often used to help increase the amount of fluid in your blood, which raises blood pressure, but it can have serious side effects. […] Another medication is pyridostigmine (Mestinon, Regonol). This drug might be more effective combined with midodrine.

• #48 Orthostatic Intolerance Treatment & Management: Medical Care, Diet, Activity

  https://emedicine.medscape.com/article/902155-treatment

  Midodrine, an a-1 adrenergic agonist, can be helpful and has few side effects apart from piloerection. […] Mestinon (pyridostigmine), an acetylcholinesterase inhibitor, alone or in combination with midodrine, can be very helpful through its potentiation of cholinergic ganglionic nerve activity and through its muscarinic effects. […] There are great expectations for Droxidopa in trials being conducted outside the United States. […] Innovative treatment with angiotensin II receptor blockers (ARBs) is under investigation. […] Enhanced salt and water intake is the common wisdom. However, evidence-based literature has only shown effect with ingestion of large quantities of salt. […] Compression garments as countermeasures to orthostatic intolerance. […] Salt supplementation improves orthostatic cerebral and peripheral vascular control in patients with syncope. […] The efficacy of midodrine hydrochloride in the treatment of children with vasovagal syncope. […] The Second Prevention of Syncope Trial (POST II)–a randomized clinical trial of fludrocortisone for the prevention of neurally mediated syncope: rationale and study design.

• #49 An Overview of Orthostatic Hypotension

  https://www.uspharmacist.com/article/an-overview-of-orthostatic-hypotension

  Midodrine, a peripheral selective direct alpha-1 adrenoreceptor agonist, is the only FDA-approved agent that is specifically indicated for treatment of orthostatic hypotension. […] Fludrocortisone, a synthetic mineralocorticoid, is used as a first-line agent. […] Clonidine, an alpha-2 receptor agonist, is used to treat orthostatic hypotension in patients with severe autonomic dysfunction. […] Pyridostigmine, an acetylcholinesterase inhibitor, may be utilized for the treatment of orthostatic hypotension. […] Combination therapy consisting of midodrine and fludrocortisone, midodrine and pyridostigmine, or midodrine and octreotide has demonstrated increases in blood pressure compared with monotherapy. […] Pharmacists have a role in educating patients about both pharmacologic and nonpharmacologic modalities for controlling and preventing the incidence and consequences of orthostatic hypotension.

• #50 Diagnosis and management of neurogenic orthostatic hypotension

  https://www.e-acn.org/journal/view.php?number=643

  Compressive garments for OH include custom-fitted elastic stockings (e.g., waist-high, thigh-high) and abdominal binder. […] Activities such as prolonged standing, alcohol consumption, hot showers, and saunas should be avoided as they augment vasodilation and venous pooling. […] If non-pharmacological treatments are not sufficient, pharmacological treatments can be used in combination. […] There are two categories of medications: NE enhancers and replacers. […] Midodrine is the most used medication for OH due to its availability, minimal drug interaction, and quick onset with predictable effects. […] Fludrocortisone, which is a synthetic mineralocorticoid analog, potentiates 1 receptor activity and expands plasma volume through the urinary reabsorption of water and salt. […] Droxidopa is an oral synthetic amino acid that provides exogenous NE, as it is converted to NE through decarboxylation. […] Pyridostigmine is a reversible cholinesterase inhibitor that potentiates cholinergic neurotransmission in the autonomic ganglia, both sympathetic and parasympathetic. […] A stepwise approach is recommended to manage N-OH symptoms.

• #51 Management of Orthostatic Hypotension

  https://pmc.ncbi.nlm.nih.gov/articles/PMC7339914/

  Fludrocortisone is a synthetic mineralocorticoid that increases renal sodium and water reabsorption, therefore expanding intravascular volume and increasing blood pressure in all positions. […] Midodrine is an oral prodrug converted peripherally into the active metabolite desglymidodrine, a selective 1-adrenoceptor agonist that constricts arteriolar and venous vasculature, thus increasing blood pressure. […] Droxidopa is an oral synthetic amino acid that converts to norepinephrine. […] An emerging approach in the treatment of neurogenic orthostatic hypotension is the use of inhibitors of the norepinephrine membrane transporter, which inhibit norepinephrine reuptake and increase its availability in the neurovascular junction. […] Treatment of postprandial hypotension includes reducing high glycemic index carbohydrates, eating smaller and more frequent meals, and using the -glucosidase inhibitor acarbose. […] Neurogenic supine hypertension is best treated with postural measures, ie, avoiding the flat position and sleeping with the head of the bed raised 30 to 45 degrees with the help of an electric bed or mattress.

• #52

  https://link.springer.com/article/10.1007/s00702-017-1791-y

  Management of cardiovascular autonomic failure may result challenging in clinical practice, relying on a combination of non-pharmacological and pharmacological measures, in which the underlying etiology, severity of symptoms and the individual risk-benefit ratio need to be taken into account. […] Non-pharmacological treatment options remain pivotal for the treatment of autonomic failure. […] At present only midodrine and droxidopa (the latter in the US and Japan only) have been approved for treatment of nOH, while the remaining substances are prescribed in an off-label regimen. […] Quality of evidence is moderate for droxidopa and the level of recommendation strong. […] In severe postprandial hypotension with limited response to conservative management (avoidance of large fat- or carbohydrate-rich meals and alcohol, increase in fluid and salt intake), acarbose in a dosage of 100 mg can be used in selected cases (quality of evidence is moderate, recommendation strong). Alternatively, subcutaneous octreotide (quality of evidence moderate, recommendation strong, 1 g/kg) may be helpful. […] The target of nOH management is improvement of patients quality of life by warranting mobility and preventing injurious falls due to syncope and pre-syncope.

• #53

  https://link.springer.com/article/10.1007/s00702-017-1791-y

  Management of cardiovascular autonomic failure may result challenging in clinical practice, relying on a combination of non-pharmacological and pharmacological measures, in which the underlying etiology, severity of symptoms and the individual risk-benefit ratio need to be taken into account. […] Non-pharmacological treatment options remain pivotal for the treatment of autonomic failure. […] At present only midodrine and droxidopa (the latter in the US and Japan only) have been approved for treatment of nOH, while the remaining substances are prescribed in an off-label regimen. […] Quality of evidence is moderate for droxidopa and the level of recommendation strong. […] In severe postprandial hypotension with limited response to conservative management (avoidance of large fat- or carbohydrate-rich meals and alcohol, increase in fluid and salt intake), acarbose in a dosage of 100 mg can be used in selected cases (quality of evidence is moderate, recommendation strong). Alternatively, subcutaneous octreotide (quality of evidence moderate, recommendation strong, 1 g/kg) may be helpful. […] The target of nOH management is improvement of patients quality of life by warranting mobility and preventing injurious falls due to syncope and pre-syncope.

• #54

  https://link.springer.com/article/10.2165/00003495-199039010-00007

  Many drugs have been used in treating patients with postural hypotension but for a large number the evidence of benefit is small and the potential for adverse effects, particularly supine hypertension, is great. […] Full clinical assessment is essential at the outset to define the nature and extent of pathophysiological disturbance of autonomic function. […] Many patients can be treated adequately by sleeping with the head of the bed elevated, and the use of fludrocortisone. […] Patients without evidence of central neurological deficit may benefit from additional treatment with drugs which alter -adrenoceptor tone. […] Patients who respond poorly to these measures should be admitted to hospital, and treatment with desmopressin initiated. […] Symptomatic postprandial hypotension should be identified early since the response to these measures alone is often poor; caffeine administered before eating, with abstinence for the rest of the day, may be very helpful.

• #55 Evaluation and management of orthostatic hypotension: Limited data, limitless opportunity | Cleveland Clinic Journal of Medicine

  https://www.ccjm.org/content/89/1/36

  Fludrocortisone is a synthetic mineralocorticoid that increases extracellular fluid volume and increases sensitivity to catecholamines. […] The vasoconstrictors midodrine and droxidopa are short-acting and therefore more useful for treatment during the daytime while avoiding supine hypertension at night. […] Importantly, most of the trials to support the above treatments are small, uncontrolled observational studies. There is much need for improvement. […] The approach to its treatment is first non-pharmacologic. Fludrocortisone should almost always be stopped. […] Pharmacologic management is often needed. Because of the problem of OH during the day, long-acting agents cannot be used. Short-acting antihypertensive drugs are given at bedtime.

• #56 Evaluation and management of orthostatic hypotension: Limited data, limitless opportunity | Cleveland Clinic Journal of Medicine

  https://www.ccjm.org/content/89/1/36

  Although orthostatic hypotension is common and can have serious consequences, recommendations about its evaluation and management are based on limited data. Here, the author outlines a systematic approach, noting the areas that pose an opportunity for improvement. […] Treatment should first focus on nondrug therapy, but when adding drug therapy such as fludrocortisone and vasoconstrictors, consider volume status and the presence or absence of supine hypertension. […] Supine hypertension is common in neurogenic orthostatic hypotension. It should be treated by discontinuing fludrocortisone and long-acting antihypertensives. Elevation of the head of the bed, high-carbohydrate snacks at bedtime, and short-acting antihypertensive drugs at bedtime, preferably nitrates or clonidine, can be useful.

• #57

  https://link.springer.com/article/10.1007/s00702-017-1791-y

  Management of cardiovascular autonomic failure may result challenging in clinical practice, relying on a combination of non-pharmacological and pharmacological measures, in which the underlying etiology, severity of symptoms and the individual risk-benefit ratio need to be taken into account. […] Non-pharmacological treatment options remain pivotal for the treatment of autonomic failure. […] At present only midodrine and droxidopa (the latter in the US and Japan only) have been approved for treatment of nOH, while the remaining substances are prescribed in an off-label regimen. […] Quality of evidence is moderate for droxidopa and the level of recommendation strong. […] In severe postprandial hypotension with limited response to conservative management (avoidance of large fat- or carbohydrate-rich meals and alcohol, increase in fluid and salt intake), acarbose in a dosage of 100 mg can be used in selected cases (quality of evidence is moderate, recommendation strong). Alternatively, subcutaneous octreotide (quality of evidence moderate, recommendation strong, 1 g/kg) may be helpful. […] The target of nOH management is improvement of patients quality of life by warranting mobility and preventing injurious falls due to syncope and pre-syncope.

• #58 Diagnosis and management of neurogenic orthostatic hypotension

  https://www.e-acn.org/journal/view.php?number=643

  Orthostatic hypotension is a sustained and pathological drop in blood pressure upon standing. […] For the management of neurogenic orthostatic hypotension, physicians should implement non-pharmacological methods and, if possible, reverse combined non-neurological conditions. […] Depending on severity of symptoms, pharmacological intervention may be tried after or with non-pharmacological methods. […] Its management should be individualized based on intensity of symptoms, comorbid conditions, drug side effects, and etiology. […] In milder cases, pharmacological agents can be used when non-pharmacological treatments are insufficient. […] But, in severe cases, both non-pharmacological and pharmacological measures may need to be started spontaneously. […] The consensus statements for N-OH management recommend a stepwise and individualized approach.

• #59 Diagnosis and management of neurogenic orthostatic hypotension

  https://www.e-acn.org/journal/view.php?number=643

  Experts suggest a 4-step treatment algorithm: a review of the patients medications, non-pharmacologic measures, initiation of a single pharmacologic agent, and combination pharmacologic agents. […] When feasible, factors that can aggravate OH should be corrected. […] If OH symptoms persist and affect daily activities after correction of the precipitating factors, non-pharmacological measures need to be considered. […] Physical counter-maneuvers such as squatting, leg-crossing, thigh contraction, and bending at the waist can reduce venous pooling and increase total peripheral resistance quickly through mechanical compression of the vein. […] An increase in water and salt intake may expand the intravascular volume and reduce the severity of OH. […] To expand circulating fluid, water intake needs to increase up to 2-2.5 L of water per day.

• #60 Postural Hypotention | Home management and remedies

  https://www.movementdisordersclinic.com/postural-hypotension/

  Postural Hypotension or Orthostatic hypotension is the process of drop in body blood pressure, when people stand up from sleeping or sitting position. Medically it is defined as a decrease in systolic blood pressure of 20 mm Hg or a decrease in diastolic blood pressure of 10 mm Hg within three minutes of standing compared with blood pressure from the sitting or supine position. […] The treatment of Postural hypotension includes non-pharmacological (without medications) and Pharmacological (with medications). Your doctor will suggest you what treatment you need to follow. In this page, we are providing some of the non pharmacological treatments to manage postural hypotension. […] Use abdominal binders and compression stockings. This will help to reduce the blood pressure drop during sudden posture changes. […] Monitor your postural BP changes and maintain a records. This will help your doctor to take decisions on your next visit. Check your BP after sleeping for atleat 5 minutes and on standing at 1min, 3min and 5mins.

• #61 Preventing and treating orthostatic hypotension: As easy as A, B, C

  https://pmc.ncbi.nlm.nih.gov/articles/PMC2888469/

  Orthostatic hypotension is a chronic, debilitating illness that is difficult to treat. The therapeutic goal is to improve postural symptoms, standing time, and function rather than to achieve upright normotension, which can lead to supine hypertension. Drug therapy alone is never adequate. […] Treatment can be challenging, especially if the problem is neurogenic. This condition has no cure, symptoms vary in different circumstances, treatment is nonspecific, and aggressive treatment can lead to marked supine hypertension. […] The goal of management of orthostatic hypotension is to raise the patients standing blood pressure without also raising his or her supine blood pressure, and specifically to reduce orthostatic symptoms, increase the time the patient can stand, and improve his or her ability to perform daily activities. No specific treatment is currently available that achieves all these goals, and drugs alone are never completely adequate.

• #62 Preventing and treating orthostatic hypotension: As easy as A, B, C | MDedge

  https://www.mdedge.com/content/preventing-and-treating-orthostatic-hypotension-easy-b-c

  Orthostatic hypotension is a chronic, debilitating illness that is difficult to treat. The therapeutic goal is to improve postural symptoms, standing time, and function rather than to achieve upright normotension, which can lead to supine hypertension. Drug therapy alone is never adequate. Because orthostatic stress varies with circumstances during the day, a patient-oriented approach that emphasizes education and nonpharmacologic strategies is critical. We provide easy-to-remember management recommendations, using a combination of drug and nondrug treatments that have proven efficacious. […] Treatment is directed at increasing blood volume, decreasing venous pooling, and increasing vasoconstriction while minimizing supine hypertension. […] Patient education and nondrug strategies alone can be effective in mild cases. Examples: consuming extra fluids and salt, wearing an abdominal binder, drinking boluses of water, raising the head of the bed, and performing countermaneuvers and physical activity.

• #63 Orthostatic Hypotension: A Practical Approach | AAFP

  https://www.aafp.org/pubs/afp/issues/2022/0100/p39.html

  Orthostatic hypotension is defined as a decrease in blood pressure of 20 mm Hg or more systolic or 10 mm Hg or more diastolic within three minutes of standing from the supine position or on assuming a head-up position of 60 degrees during tilt table testing. Symptoms are due to inadequate physiologic compensation and organ hypoperfusion and include headache, lightheadedness, shoulder and neck pain (coat hanger syndrome), visual disturbances, dyspnea, and chest pain. […] Treatment goals for orthostatic hypotension are reducing symptoms and improving quality of life. Initial treatment focuses on the underlying cause and adjusting potentially causative medications. Nonpharmacologic strategies include dietary modifications, compression garments, physical maneuvers, and avoiding environments that exacerbate symptoms. First-line medications include midodrine and droxidopa. Although fludrocortisone improves symptoms, it has concerning long-term effects.

• #64 Evaluation and management of orthostatic hypotension: Limited data, limitless opportunity | Cleveland Clinic Journal of Medicine

  https://www.ccjm.org/content/89/1/36

  Most causes of OH requiring long-term treatment are neurogenic. A consensus panel assembled by the American Autonomic Society and the National Parkinson Foundation recommends a stepwise approach to the treatment of neurogenic OH. […] Step 1 is a detailed medication review to identify drugs that often cause OH. Long-acting antihypertensives almost always should be stopped. […] Step 2 is the addition of nonpharmacologic measures. Exercise increases muscle tone and improves venomotor competence, reducing venous pooling, but should be either recumbent (eg, on a recumbent bike or rowing machine) or aquatic (swimming or pool-walking) to maximize tolerability. […] I recommend high sodium (150 mEq/day) and fluid (at least 2 L/day) intake to most patients. […] Step 3 is drug treatment. Despite the absence of high-quality evidence to support their use, the cornerstone drugs are fludrocortisone, midodrine, and droxidopa; pyridostigmine and atomoxetine are used less often.

• #65 Management of Postural Hypotension in Parkinson’s | Neurology Academy

  https://neurologyacademy.org/events/webinar/management-of-postural-hypotension-in-parkinsons

  He summarised the treatment of orthostatic hypotension in the following slide: Orthostatic Hypotension is a common problem not just in Parkinsons. […] Treat symptoms – not blood pressure – but need to discuss risks. […] Use 4-step approach in treatment. […] Patient education and self management. […] GRAVITY is both friend and enemy.

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