Skip to main content

Advertisement

SpringerLink
Log in

Current pharmacologic treatment for orthostatic hypotension

  • ARTICLE
  • Published:
Clinical Autonomic Research Aims and scope Submit manuscript

Abstract

Orthostatic hypotension is treated effectively with the combined use of non-pharmacological and pharmacological interventions. Patients should be counseled as to the nature of the underlying disorder and reversible causes of orthostatic hypotension should be removed. Should symptoms persist, pharmacological treatment is implemented. First line pharmacotherapeutic interventions include volume repletion in combination with alpha-adrenoreceptor agonists. If unsuccessful there are several supplementary agents with different mechanisms of action that may provide an additive effect.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Biaggioni I, Onrot J, Stewart CK, Robertson D (1987) The potent pressor effect of phenylpropanolamine in patients with autonomic impairment. JAMA 258:236–239

    Article  PubMed  CAS  Google Scholar 

  2. Biaggioni I, Robertson D, Krantz S, Jones M, Haile V (1994) The anemia of primary autonomic failure and its reversal with recombinant erythropoietin. Ann Intern Med 121:181–186

    PubMed  CAS  Google Scholar 

  3. Campbell IW, Ewing DJ, Clarke BF (1975) 9-Alpha-fluorohydrocortisone in the treatment of postural hypotension in diabetic autonomic neuropathy. Diabetes 24:381–384

    Article  PubMed  CAS  Google Scholar 

  4. Chobanian AV, Volicer L, Tifft CP, Gavras H, Liang CS, Faxon D (1979) Mineralocorticoid-induced hypertension in patients with orthostatic hypotension. N Engl J Med 301:68–73

    Article  PubMed  CAS  Google Scholar 

  5. Cleophas TJ, Grabowsky I, Niemeyer MG, Makel WM, van der Wall EE (2002) Paradoxical pressor effects of beta-blockers in standing elderly patients with mild hypertension: a beneficial side effect. Circulation 105:1669–1671

    Article  PubMed  CAS  Google Scholar 

  6. Davies B, Bannister R, Sever P (1978) Pressor amines and monoamine-oxidase inhibitors for treatment of postural hypotension in autonomic failure. Limitations and hazards. Lancet 1:172–175

    Article  PubMed  CAS  Google Scholar 

  7. Davies IB, Bannister RG, Sever PS, Wilcox CS (1978) Fludrocortisone in the treatment of postural hypotension: altered sensitivity to pressor agents [proceedings]. Br J Clin Pharmacol 6:444P–445P

    PubMed  CAS  Google Scholar 

  8. Fouad-Tarazi FM, Okabe M, Goren H (1995) Alpha sympathomimetic treatment of autonomic insufficiency with orthostatic hypotension. Am J Med 99:604–610

    Article  PubMed  CAS  Google Scholar 

  9. Freeman R (2003) Treatment of orthostatic hypotension Semin Neurol 23:435–442

    Article  PubMed  Google Scholar 

  10. Ghrist DG, Brown GE (1928) Postural hypertension with syncope: its successful treatment with ephedrine. Am J Med Sci 175:336–349

    Article  Google Scholar 

  11. Hickler RB, Thompson GR, Fox LM, Hamlin JT (1959) Successful treatment of orthostatic hypotension with 9-alpha-fluorohydrocortisone. N Engl J Med 261:788–791

    Article  PubMed  CAS  Google Scholar 

  12. Hoeldtke RD, Streeten DHP, Streeten DH (1993) Treatment of orthostatic hypotension with erythropoietin. N Engl J Med 329:611–615

    Article  PubMed  CAS  Google Scholar 

  13. Jordan J, Shannon JR, Biaggioni I, Norman R, Black BK, Robertson D (1998) Contrasting actions of pressor agents in severe autonomic failure. Am J Med 105:116–124

    Article  PubMed  CAS  Google Scholar 

  14. Jordan J, Shannon JR, Black BK, Ali Y, Farley M, Costa F, Diedrich A, Robertson RM, Biaggioni I, Robertson D (2000) The pressor response to water drinking in humans: a sympathetic reflex? Circulation 101:504–509

    PubMed  CAS  Google Scholar 

  15. Kaufmann H, Brannan T, Krakoff L, Yahr MD, Mandeli J (1988) Treatment of orthostatic hypotension due to autonomic failure with a peripheral alpha-adrenergic agonist (midodrine). Neurology 38:951–956

    PubMed  CAS  Google Scholar 

  16. Kernan WN, Viscoli CM, Brass LM, Broderick JP, Brott T, Feldmann E, Morgenstern LB, Wilterdink JL, Horwitz RI (2000) Phenylpropanolamine and the risk of hemorrhagic stroke. N Engl J Med 343:1826–1832

    Article  PubMed  CAS  Google Scholar 

  17. Leslie PJ, Thompson C, Clarke BF, Ewing DJ (1991) A double-blind crossover study of oral xamoterol in postural hypotension due to diabetic autonomic neuropathy. Clin Auton Res 1:119–123

    Article  PubMed  CAS  Google Scholar 

  18. van Lieshout JJ, ten Harkel AD, Wieling W. (2000) Fludrocortisone and sleeping in the head-up position limit the postural decrease in cardiac output in autonomic failure. Clin Auton Res 10:35–42

    Article  PubMed  Google Scholar 

  19. Lipsitz LA, Ryan SM, Parker JA, Freeman R, Wei JY, Goldberger AL. (1993) Hemodynamic and autonomic nervous system responses to mixed meal ingestion in healthy young and old subjects and dysautonomic patients with postprandial hypotension. Circulation 87:391–400

    PubMed  CAS  Google Scholar 

  20. Low PA, Gilden JL, Freeman R, Sheng KN, McElligott MA (1997) Efficacy of midodrine vs placebo in neurogenic orthostatic hypotension. A randomized, doubleblind multicenter study. Midodrine Study Group. JAMA 277:1046–1051

    Article  PubMed  CAS  Google Scholar 

  21. Mathias CJ, Fosbraey P, da Costa DF, Thornley A, Bannister R (1986) The effect of desmopressin on nocturnal polyuria, overnight weight loss, and morning postural hypotension in patients with autonomic failure. Br Med J Clin Res 293:353–354

    CAS  Google Scholar 

  22. Mehlsen J, Trap-Jensen J (1986) Xamoterol, a new selective beta-1-adrenoceptor partial agonist, in the treatment of postural hypotension. Acta Med Scand 219:173–177

    Article  PubMed  CAS  Google Scholar 

  23. Obara A, Yamashita H, Onodera S, Yahara O, Honda H, Hasebe N (1992) Effect of xamoterol in Shy-Drager syndrome. Circulation 85:606–611

    PubMed  CAS  Google Scholar 

  24. Omboni S, Smit AA, van Lieshout JJ, Settels JJ, Langewouters GJ, Wieling W (2001) Mechanisms underlying the impairment in orthostatic tolerance after nocturnal recumbency in patients with autonomic failure. Clin Sci (Lond) 101:609–618

    Article  CAS  Google Scholar 

  25. Onrot J, Goldberg MR, Biaggioni I, Hollister AS, Kingaid D, Robertson D (1985) Hemodynamic and humoral effects of caffeine in autonomic failure. Therapeutic implications for postprandial hypotension. N Engl J Med 313:549–554

    Article  PubMed  CAS  Google Scholar 

  26. Onrot J, Goldberg MR, Biaggioni I, Wiley RG, Hollister AS, Robertson D (1987) Oral yohimbine in human autonomic failure. Neurology 37:215–220

    PubMed  CAS  Google Scholar 

  27. Ozawa T, Tanaka H, Nakano R, Sato M, Inuzuka T, Soma Y, Yoshimura N, Fukuhara N, Tsuji S (1999) Nocturnal decrease in vasopressin secretion into plasma in patients with multiple system atrophy. J Neurol Neurosurg Psychiatry 67:542–545

    Article  PubMed  CAS  Google Scholar 

  28. Perera R, Isola L, Kaufmann H (1995) Effect of recombinant erythropoietin on anemia and orthostatic hypotension in primary autonomic failure. Clin Auton Res 5:211–213

    Article  PubMed  CAS  Google Scholar 

  29. Rao SV, Stamler JS (2002) Erythropoietin, anemia, and orthostatic hypotension: the evidence mounts. Clin Auton Res 12:141–143

    Article  PubMed  Google Scholar 

  30. Robertson D, Goldberg MR, Hollister AS, Wade D, Robertson RM (1983) Clonidine raises blood pressure in idiopathic orthostatic hypotension. Am J Med 74:193–199

    Article  PubMed  CAS  Google Scholar 

  31. Robertson D, Goldberg MR, Tung CS, Hollister AS, Robertson RM. (1986) Use of alpha 2 adrenoreceptor agonists and antagonists in the functional assessment of the sympathetic nervous system. J Clin Invest 78:576–581

    Article  PubMed  CAS  Google Scholar 

  32. Robertson D, Wade D, Robertson RM (1981) Postprandial alterations in cardiovascular hemodynamics in autonomic dysfunction states. Am J Cardiol 48:1048–1052

    Article  PubMed  CAS  Google Scholar 

  33. Sakakibara R, Matsuda S, Uchiyama T, Yoshiyama M, Yamanishi T, Hattori T (2003) The effect of intranasal desmopressin on nocturnal waking in urination in multiple system atrophy patients with nocturnal polyuria. Clin Auton Res 13:106–108

    Article  PubMed  Google Scholar 

  34. Schatz IJ, Miller MJ, Frame B (1976) Corticosteroids in the management of orthostatic hypotension. Cardiology 61(suppl 1):280–289

    PubMed  Google Scholar 

  35. Singer W, Opfer-Gehrking TL, McPhee BR, Hilz MJ, Bharucha AE, Low PA (2003) Acetylcholinesterase inhibition: a novel approach in the treatment of neurogenic orthostatic hypotension. J Neurol Neurosurg Psychiatry 74:1294–1298

    Article  PubMed  CAS  Google Scholar 

  36. Victor RG, Talman WT (2002) Comparative effects of clonidine and dihydroergotamine on venomotor tone and orthostatic tolerance in patients with severe hypoadrenergic orthostatic hypotension. Am J Med 112:361–368

    Article  PubMed  CAS  Google Scholar 

  37. West JN, Stallard TJ, Dimmitt SB, Smith SA, Williams A, Littler WA (1990) Xamoterol in the treatment of orthostatic hypotension associated with multiple system atrophy (Shy-Drager syndrome). Q J Med 74:209–213

    PubMed  CAS  Google Scholar 

  38. Wieling W, van Lieshout JJ, Hainsworth R (2002) Extracellular fluid volume expansion in patients with posturally related syncope. Clin Auton Res 12:242–249

    Article  PubMed  CAS  Google Scholar 

  39. Wieling W, van Lieshout JJ, van Leeuwen AM (1993) Physical manoeuvres that reduce postural hypotension in autonomic failure. Clin Auton Res 3:57–65

    Article  PubMed  CAS  Google Scholar 

  40. Winkler AS, Landau S, Watkins P, Chaudhuri KR (2002) Observations on haematological and cardiovascular effects of erythropoietin treatment in multiple system atrophy with sympathetic failure. Clin Auton Res 12:203–206

    Article  PubMed  Google Scholar 

  41. Winkler AS, Marsden J, Parton M, Watkins PJ, Chaudhuri KR (2001) Erythropoietin deficiency and anaemia in multiple system atrophy. Mov Disord 16:233–239

    Article  PubMed  CAS  Google Scholar 

  42. Wright RA, Kaufmann HC, Perera R, Opfer-Gehrking TL, McElligott MA, Sheng KN, Low PA (1998) A double-blind, dose-response study of midodrine in neurogenic orthostatic hypotension. Neurology 51:120–124

    PubMed  CAS  Google Scholar 

Download references

Disclosure

Dr. Freeman has served as a consultant for Chelsea Therapeutics.

Author information

Authors and Affiliations

  1. Dept. of Neurology Harvard Medical School, Center for Autonomic and Peripheral Nerve Disorders Beth Israel Deaconess Medical Center, One Deaconess Road, Boston, MA, 02215, USA

    Roy Freeman MD

Authors
  1. Roy Freeman MD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Roy Freeman MD.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Freeman, R. Current pharmacologic treatment for orthostatic hypotension. Clin Auton Res 18 (Suppl 1), 14–18 (2008). https://doi.org/10.1007/s10286-007-1003-1

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10286-007-1003-1

Key words

Search

Navigation