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Selected drugs for orthostatic hypotension

Selected drugs for orthostatic hypotension
Drug Dose Pharmacokinetic considerations Mechanism of action Major side effects and precautions
Approved for orthostatic hypotension
Midodrine

2.5 to 10 mg up to 3 times daily.

Administer in the morning, midday, and/or 3 to 4 hours before bedtime; individualize to patient need.
Short acting (peak effect 1 hour; duration 2 to 3 hours). Alpha-1-adrenergic receptor agonist

Supine hypertension, piloerection ("goose flesh"), scalp itching, urinary retention.

Use with caution in patients with congestive heart failure and chronic renal failure.
Droxidopa

100 to 600 mg up to 3 times daily.

Administer in the morning, midday, and/or 3 to 4 hours before bedtime; individualize to patient need.
Short acting (peak effect 3.5 hours; duration 5 to 6 hours). Synthetic norepinephrine precursor

Supine hypertension, headache, nausea, fatigue.

Use with caution in patients with congestive heart failure and chronic renal failure.
Not specifically approved for orthostatic hypotension
Atomoxetine 10 to 18 mg 2 times daily.

Short acting.

Most effective for patients with central autonomic dysfunction.
Norepinephrine reuptake inhibitor Supine hypertension, insomnia, irritability, decreased appetite.
Fludrocortisone

0.05 to 0.2 mg once daily in the morning.

Doses >0.2 mg/day are not more effective and have greater adverse effects.

Long acting.

Clinical effect is observed after ≥7 days of treatment.
Synthetic mineralocorticoid, volume expander that increases sodium and water reabsorption

Short-term use: Supine hypertension, hypokalemia*, edema.

Long-term use: Hypertension and target organ damage (eg, left ventricular hypertrophy), renal failure.

Use with caution in patients with congestive heart failure.
Pyridostigmine 30 to 60 mg 2 or 3 times daily. Short acting. Acetylcholinesterase inhibitor Abdominal cramps, diarrhea, sialorrhea, excessive sweating, urinary incontinence.
Dosing in this table is for oral medications used to treat orthostatic hypotension. For further information, including agent selection, refer to the UpToDate clinical topic review of treatment of orthostatic hypotension.
* A potassium-rich diet or potassium supplementation (eg, 20 mEq/day) is recommended during treatment.
From: Palma JA, Kaufmann H. Management of orthostatic hypotension. Continuum 2020; 26:154. DOI: 10.1212/CON.0000000000000816. Copyright © 2020 American Academy of Neurology. Reproduced with permission from Wolters Kluwer Health. Unauthorized reproduction of this material is prohibited.
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