Orthostatic Hypotension Management

Patient Selection and Dosing

The European Heart Journal recommends that midodrine should be used with caution in elderly patients with orthostatic hypotension due to increased risk of supine hypertension, urinary retention, and other adverse effects that are particularly problematic in this population 1
Consider midodrine only after non-pharmacological interventions have been implemented, including increased salt/fluid intake, compression garments, physical counter-maneuvers, and elevation of head of bed by 10-15 cm, as suggested by the American College of Cardiology 2
Begin with a low dose of 2.5 mg three times daily and titrate slowly based on response and tolerability, as recommended by the American Heart Association 2

The American College of Cardiology suggests that droxidopa may be a better-tolerated alternative to midodrine in some elderly patients 2
Fludrocortisone is an alternative option at 0.05-0.1 mg daily, titrated to 0.1-0.3 mg daily, as recommended by the American Heart Association 2
Pyridostigmine may benefit patients without the risks of fluid retention or supine hypertension, according to the Journal of the American College of Cardiology 3

Regularly monitor both standing and supine blood pressure, renal function, and symptoms of supine hypertension, bradycardia, and urinary retention, as recommended by the European Heart Journal 1
Be aware of the potential for enhanced pressor effects when combining midodrine with other vasoconstrictors, and the risk of cardiac effects when used with cardiac glycosides, as suggested by the American College of Cardiology 2