Classification of Antihypertensives Based on Potential to Cause Postural Hypotension

High Risk of Postural Hypotension

• Alpha-blockers are consistently identified as having a high risk of causing postural hypotension, according to the British Hypertension Society and other guidelines 1, 2
• The British Hypertension Society guidelines explicitly list postural hypotension as a caution when using alpha-blockers, such as prazosin, doxazosin, and terazosin 4, 2

Moderate Risk of Postural Hypotension

• Centrally-acting agents, such as clonidine and methyldopa, are associated with a significant incidence of orthostatic hypotension and are generally reserved as last-line therapy due to this adverse effect profile 5
• Thiazide and thiazide-like diuretics can cause volume depletion that may precipitate orthostatic hypotension, particularly in elderly patients 3

Low Risk of Postural Hypotension

• Calcium Channel Blockers (CCBs), such as amlodipine, have not been associated with significant orthostatic hypotension in clinical trials, and are often recommended for elderly patients with isolated systolic hypertension 2, 6
• ACE inhibitors and ARBs have minimal association with orthostatic hypotension in clinical trials and are not listed with postural hypotension as a caution in major hypertension guidelines 4, 2

Special Considerations

• Guidelines recommend measuring blood pressure in both sitting and standing positions in elderly patients to detect orthostatic changes, as orthostatic hypotension occurs more commonly in this population 6
• Initial doses and subsequent dose titration should be more gradual in elderly patients due to increased risk of orthostatic effects, and patients should be educated about potential symptoms and preventive measures 6, 3