Drug treatment for orthostatic hypotension
If symptomatic orthostatic hypotension persists despite nondrug measures, consider referral to a specialist physician with experience managing orthostatic hypotension (eg cardiologist, general physician, geriatrician).
Fludrocortisone is a synthetic mineralocorticoid that expands plasma volume and is thus contraindicated in heart failure and hypertension. Although it has historically been used for orthostatic hypotension, the evidence for its benefit is of low certainty, especially in the long term.
Midodrine is a short-acting vasopressor that is effective in severe symptomatic orthostatic hypotension due to autonomic failure. Midodrine therapy should be directed by a specialist physician.
Hypertension with coexisting orthostatic hypotension should be treated with angiotensin converting enzyme inhibitors, angiotensin II receptor blockers or dihydropyridine calcium channel blockers in preference to alpha blockers, beta blockers or diuretics (unless specifically indicated). Consider afternoon or evening dosing, particularly for patients with nocturnal supine hypertension.