Orthostatic hypotension

Orthostatic hypotension, a drop in blood pressure upon standing, can result from various causes like diabetes or medications. Symptoms include dizziness and fainting. Non-drug measures like exercise and proper hydration are first-line treatments. If necessary, medications like fludrocortisone or pressor agents such as midodrine and droxidopa may be prescribed for moderate to severe cases. Second-line treatments like erythropoietin, caffeine, and pyridostigmine may also be considered but have limited evidence of effectiveness.

2024-01-01 01:42:35 - Editor

Definition and Diagnostic Criteria

Orthostatic hypotension occurs due to a sudden change in posture, and can be associated with meals or prolonged standing. It's diagnosed as a decrease of at least 20 mmHg in systolic blood pressure or 10 mmHg in diastolic blood pressure within 2 minutes of standing. Symptoms typically include dizziness, blurred vision, lightheadedness, darkening of the visual fields, and potentially syncope. Common causes include autonomic neuropathy resulting from conditions like diabetes mellitus, amyloidosis, Sjögren syndrome, chronic renal failure, vitamin B12 deficiency, toxins, infections (syphilis, HIV, Lyme, Chagas), sarcoidosis, and neurodegenerative diseases (Parkinson's, dementia with Lewy bodies, Shy-Drager syndrome). It can also be a side effect of certain medications. (1, 2, 3)

Non-Pharmacological Management

Initial management focuses on non-pharmacological interventions and patient education. These include discontinuing or adjusting medications that may contribute to orthostatic hypotension, encouraging physical exercise, and advising patients to rise slowly from a lying to a standing position. Other measures include avoiding straining, violent coughing, and exposure to hot weather, which can exacerbate symptoms. Ensuring adequate hydration is also crucial. (4)

Pharmacological Treatment

When non-pharmacological measures are insufficient, pharmacological agents are used, especially in moderate to severe cases. Fludrocortisone acetate is often the first-line medication. If needed, other pressor agents like midodrine and droxidopa can be used, either in combination with fludrocortisone or as standalone treatments in those who cannot tolerate fludrocortisone's side effects. (5)

Second-Line Pharmacological Options

Erythropoietin, caffeine, and pyridostigmine are considered second-line treatments for orthostatic hypotension. However, the evidence supporting their efficacy is limited. (6)

References

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