CNS Drugs

, Volume 25, Issue 8, pp 659–671 | Cite as

Antipsychotic Pharmacotherapy and Orthostatic Hypotension

Identification and Management
  • James J. GuggerEmail author
Therapy in Practice


Orthostatic hypotension is a common adverse effect of antipsychotics that may delay or prevent titration to a dose necessary to control psychotic symptoms. Complications of orthostatic hypotension include syncope, transient ischaemic attack, stroke, myocardial infarction and death. The risk of orthostatic hypotension associated with antipsychotic therapy is increased in patients with disorders of the autonomic nervous system, fluid imbalance and those taking concomitant drug therapy that affects haemodynamic tone. Prospective monitoring for changes in postural blood pressure is important because patients with psychotic disorders often do not articulate symptoms of orthostasis and the subjective report of dizziness does not correlate well with orthostatic blood pressure changes.

Nonpharmacological strategies and patient education, most notably, slowly rising from the supine position, are crucial first steps in the prevention and treatment of both symptomatic and asymptomatic orthostatic hypotension. Pharmacological treatment is only recommended when symptomatic orthostatic hypotension persists despite proper nonpharmacological therapy and there is a compelling indication for antipsychotic treatment. Fludrocortisone is a reasonable first choice for symptomatic orthostatic hypotension. Other agents including desmopressin and midodrine may be considered in patients who do not respond favourably to a trial of fludrocortisone, but safety concerns and lack of evidence limit the utility of these agents.


Clozapine Quetiapine Orthostatic Hypotension Tamsulosin Guanfacine 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



No funding was used to prepare this manuscript. The author has no real or potential conflicts of interest.

The author would like to thank Christine Lee, PharmD, for conducting the initial literature review during a pharmacy clerkship at St. John’s University.


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© Adis Data Information BV 2011

Authors and Affiliations

  1. 1.Department of Clinical Pharmacy Practice, College of Pharmacy and Allied Health ProfessionsSt. John’s UniversityJamaicaUSA

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