NEUROGENIC ORTHOSTATIC HYPOTENSION: TREATMENTS | |||||||
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STEP 1: Medication review Modify and/or discontinue drugs that can induce or exacerbate OH: • Dopaminergic agents • Antidepressants (esp. TCAs)* • Anticholinergics • Antihypertensives: diuretics*, nitrates*, alpha-1 blockers*, calcium channel blockers, hydralazine, minoxidil, beta-blockers, clonidine, alpha-methyldopa, ACEIs, ARBs • PDE5 inhibitors |
2 week assessment ⇨ |
Incorporate daily: • Blood volume repletion • Salt intake adjustment • Physical conditioning • Core body temperature regulation • Head of bed elevation • Compression garment use† • Diet modification • B12 deficiency/anemia correction |
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2 week assessment | |||||||
STEP 4: Combination pharmacologic measures • Initiate a second agent if deemed necessary • Begin at lowest starting dose and titrate to maximum tolerated dose |
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• Midodrine • Droxidopa • Fludrocortisone • Pyridostigmine |
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Single-Agent Pharmacologic Treatments | Drug | Indication Status | Usual Dose | Notes | |||||||||||||||||||||
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Midodrine |
FDA-approved |
2.5–15mg once to three times daily while awake; titrate based on response |
• Avoid within 5hrs of bedtime due to risk of supine hypertension • Caution in CHF, chronic renal failure |
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Droxidopa |
FDA-approved |
100–600mg three times daily while awake; titrate every 48hrs based on response and/or tolerability |
• Avoid within 5hrs of bedtime due to risk of supine hypertension • Caution in CHF, chronic renal failure |
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Fludrocortisone |
Off-label |
0.1–0.2mg once daily; max 0.3mg/day |
• Caution in CHF |
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Pyridostigmine |
Off-label |
30–60mg once to three times daily |
• Beneficial in less severe patients • Does not worsen supine hypertension |
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NOTES | |||||||||||||||||||||||||
Key: ACEI = angiotensin converting enzyme inhibitor; ARB = angiotensin receptor blocker; CHF = congestive heart failure; nOH = neurogenic orthostatic hypotension; OH = orthostatic hypotension; PDE5 = phosphodiesterase E5; TCA = tricyclic antidepressant * Causes significant worsening of OH/nOH. † Waist-high compression garments are the most effective, followed by thigh-high compression stockings. Abdominal binders are effective alternatives, which can be used alone or in combination with leg compression if needed. |
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REFERENCE | |||||||||||||||||||||||||
Gibbons CH, Schmidt P, Biaggiono I, et al. The recommendations of a consensus panel for the screening, diagnosis, and treatment of neurogenic orthostatic hypotension and associated supine hypertension. J Neurol. 2017 Jan 3. doi: 10.1007/s00415-016-8375-x. Created 12/2019 |
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