Treating Lows: Management of Orthostatic Hypotension

Abstract

Orthostatic hypotension is a prevalent clinical condition, caused by heterogenous aetiologies and associated with significant morbidity and mortality. Management is particularly challenging in patients with uncontrolled hypertension. A thorough assessment is needed to draw an appropriate management plan. The treatment aims to improve postural symptoms while minimising side effects and reducing iatrogenic exacerbation of supine hypertension. A personalised management plan including rationalising medications, patient education, identification, and avoidance of triggers, as well as non-pharmacological therapies such as compression devices, dietary modifications, and postural aids, make the first steps. Among pharmacological therapies, midodrine and fludrocortisone are the most prescribed and best studied; pyridostigmine, atomoxetine, and droxidopa are considered next. Yohimbine remains an investigational agent. A multi-disciplinary team may be required in some patients with multiple comorbidities and polypharmacy. However, there’s a lack of robust efficacy and safety evidence for all therapies. Building robust real-world and stratified clinical trials based on underlying pathophysiology may pave the way for further drug development and better clinical strategies and in this challenging unmet medical need.