Preventing and treating orthostatic hypotension: As easy as A, B, C
ABSTRACTOrthostatic 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.
KEY POINTS
- 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.
- Moderate and severe cases require additional drug treatment. Pyridostigmine (Mestinon) is helpful in moderate cases. Fludrocortisone (Florinef) and midodrine (ProAmatine) are indicated in more severe cases.
F: Fluid and salt (volume expansion)
Maintaining an adequate plasma volume is crucial. Patients should drink five to eight 8-ounce glasses (1.25 to 2.5 L) of water or other fluid per day. Many elderly people do not take in this much. The patient should have at least 1 glass or cup of fluid with meals and at least twice at other times of each day to obtain 1 L/day.
Salt intake should be between 150 and 250 mmol of sodium (10 to 20 g of salt) per day. Sodium helps with retention of ingested fluids and should be maximized if tolerated. However, caution should be exercised in patients who have severe refractory supine hypertension, uncontrolled hypertension, or comorbidities characterized by insterstitial edema (eg, heart failure, liver failure). Some patients are very sensitive to sodium supplementation and can fine-tune their orthostatic control with salt alone. If salting food is not desired, prepared soups, pretzels, potato chips, and 0.5- or 1.0-g salt tablets can be an option.
Patients need to maintain a high-potassium diet, as the high sodium intake combined with fludrocortisone promotes potassium loss. Fruits (especially bananas) and vegetables have high potassium content.
The combination of fludrocortisone and a high-salt diet can also cause sustained supine hypertension, which can be minimized by the interventions noted in Table 2.
Appropriate salt supplementation and fluid intake leading to an adequate volume expansion can be verified by checking the 24-hour urinary sodium content: patients who excrete less than 170 mmol can be treated with 1 to 2 g of supplemental sodium three times a day.38
