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Treatment of orthostatic and postprandial hypotension

Horacio Kaufmann, MD
Norman M Kaplan, MD
Section Editor
Michael J Aminoff, MD, DSc
Deputy Editor
Janet L Wilterdink, MD


When autonomic reflexes are impaired or intravascular volume is markedly depleted, a significant reduction in blood pressure occurs upon standing (ie, orthostatic hypotension). Orthostatic hypotension can cause dizziness, syncope, and even angina or stroke.

Symptomatic falls in blood pressure after standing or eating are a frequent clinical problem. The prevalence of orthostatic hypotension varies from 5 to 20 percent in different reports. Many disorders can cause orthostatic hypotension, which can also be a symptom of acute or chronic volume depletion. A related problem, postprandial hypotension (a fall in blood pressure occurring 15 to 90 minutes after meals) is also common in older patients. Orthostatic hypotension can be a disabling condition and is also a risk factor for cardiovascular and all-cause mortality, as well as falls with attendant morbidity.

This topic will review the treatment of chronic orthostatic and postprandial hypotension. The patient with acute orthostatic hypotension due to volume depletion should be treated with volume replacement.

The causes and evaluation of orthostatic hypotension are discussed separately. POTS is also discussed separately (See "Mechanisms, causes, and evaluation of orthostatic hypotension" and "Postural tachycardia syndrome".)


In general, treatment is titrated to symptoms relief rather than correction of measured orthostatic hypotension. Asymptomatic orthostatic hypotension is common and of uncertain clinical relevance [1].


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Literature review current through: Jul 2015. | This topic last updated: May 6, 2015.
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  1. Miller ER 3rd, Appel LJ. High prevalence but uncertain clinical significance of orthostatic hypotension without symptoms. Circulation 2014; 130:1772.
  2. Mills PB, Fung CK, Travlos A, Krassioukov A. Nonpharmacologic management of orthostatic hypotension: a systematic review. Arch Phys Med Rehabil 2015; 96:366.
  3. Raj SR, Coffin ST. Medical therapy and physical maneuvers in the treatment of the vasovagal syncope and orthostatic hypotension. Prog Cardiovasc Dis 2013; 55:425.
  4. Wieling W, Raj SR, Thijs RD. Are small observational studies sufficient evidence for a recommendation of head-up sleeping in all patients with debilitating orthostatic hypotension? MacLean and Allen revisited after 70 years. Clin Auton Res 2009; 19:8.
  5. Fan CW, Gasparro D, Crowley V, Cunningham CJ. Acute haemodynamic response to sleeping head-up at 6 inches in older inpatients. Clin Auton Res 2009; 19:51.
  6. Fan CW, Walsh C, Cunningham CJ. The effect of sleeping with the head of the bed elevated six inches on elderly patients with orthostatic hypotension: an open randomised controlled trial. Age Ageing 2011; 40:187.
  7. Henry R, Rowe J, O'Mahony D. Haemodynamic analysis of efficacy of compression hosiery in elderly fallers with orthostatic hypotension. Lancet 1999; 354:45.
  8. Podoleanu C, Maggi R, Brignole M, et al. Lower limb and abdominal compression bandages prevent progressive orthostatic hypotension in elderly persons: a randomized single-blind controlled study. J Am Coll Cardiol 2006; 48:1425.
  9. Carroll JF, Wood CE, Pollock ML, et al. Hormonal responses in elders experiencing pre-syncopal symptoms during head-up tilt before and after exercise training. J Gerontol A Biol Sci Med Sci 1995; 50:M324.
  10. van Lieshout JJ, ten Harkel AD, Wieling W. Physical manoeuvres for combating orthostatic dizziness in autonomic failure. Lancet 1992; 339:897.
  11. Ten Harkel AD, van Lieshout JJ, Wieling W. Effects of leg muscle pumping and tensing on orthostatic arterial pressure: a study in normal subjects and patients with autonomic failure. Clin Sci (Lond) 1994; 87:553.
  12. Krediet CT, Go-Schön IK, Kim YS, et al. Management of initial orthostatic hypotension: lower body muscle tensing attenuates the transient arterial blood pressure decrease upon standing from squatting. Clin Sci (Lond) 2007; 113:401.
  13. Clarke DA, Medow MS, Taneja I, et al. Initial orthostatic hypotension in the young is attenuated by static handgrip. J Pediatr 2010; 156:1019.
  14. Thijs RD, Wieling W, van den Aardweg JG, van Dijk JG. Respiratory countermaneuvers in autonomic failure. Neurology 2007; 69:582.
  15. Smit AA, Wieling W, Fujimura J, et al. Use of lower abdominal compression to combat orthostatic hypotension in patients with autonomic dysfunction. Clin Auton Res 2004; 14:167.
  16. Figueroa JJ, Singer W, Sandroni P, et al. Effects of patient-controlled abdominal compression on standing systolic blood pressure in adults with orthostatic hypotension. Arch Phys Med Rehabil 2015; 96:505.
  17. Shannon JR, Diedrich A, Biaggioni I, et al. Water drinking as a treatment for orthostatic syndromes. Am J Med 2002; 112:355.
  18. Young TM, Mathias CJ. The effects of water ingestion on orthostatic hypotension in two groups of chronic autonomic failure: multiple system atrophy and pure autonomic failure. J Neurol Neurosurg Psychiatry 2004; 75:1737.
  19. Humm AM, Mason LM, Mathias CJ. Effects of water drinking on cardiovascular responses to supine exercise and on orthostatic hypotension after exercise in pure autonomic failure. J Neurol Neurosurg Psychiatry 2008; 79:1160.
  20. Nwazue VC, Raj SR. Confounders of vasovagal syncope: orthostatic hypotension. Cardiol Clin 2013; 31:89.
  21. Fedorowski A, Melander O. Syndromes of orthostatic intolerance: a hidden danger. J Intern Med 2013; 273:322.
  22. Shibao C, Lipsitz LA, Biaggioni I. ASH position paper: evaluation and treatment of orthostatic hypotension. J Clin Hypertens (Greenwich) 2013; 15:147.
  23. Lanier JB, Mote MB, Clay EC. Evaluation and management of orthostatic hypotension. Am Fam Physician 2011; 84:527.
  24. Jansen RW, Lipsitz LA. Postprandial hypotension: epidemiology, pathophysiology, and clinical management. Ann Intern Med 1995; 122:286.
  25. Lipsitz LA, Nyquist RP Jr, Wei JY, Rowe JW. Postprandial reduction in blood pressure in the elderly. N Engl J Med 1983; 309:81.
  26. Logan IC, Witham MD. Efficacy of treatments for orthostatic hypotension: a systematic review. Age Ageing 2012; 41:587.
  27. Schoffer KL, Henderson RD, O'Maley K, O'Sullivan JD. Nonpharmacological treatment, fludrocortisone, and domperidone for orthostatic hypotension in Parkinson's disease. Mov Disord 2007; 22:1543.
  28. Low PA, Singer W. Management of neurogenic orthostatic hypotension: an update. Lancet Neurol 2008; 7:451.
  29. Campbell IW, Ewing DJ, Clarke BF. 9-Alpha-fluorohydrocortisone in the treatment of postural hypotension in diabetic autonomic neuropathy. Diabetes 1975; 24:381.
  30. Davies IB, Bannister RG, Sever PS, Wilcox CS. Fludrocortisone in the treatment of postural hypotension: altered sensitivity to pressor agents [proceedings]. Br J Clin Pharmacol 1978; 6:444P.
  31. Chobanian AV, Volicer L, Tifft CP, et al. Mineralocorticoid-induced hypertension in patients with orthostatic hypotension. N Engl J Med 1979; 301:68.
  32. Hussain RM, McIntosh SJ, Lawson J, Kenny RA. Fludrocortisone in the treatment of hypotensive disorders in the elderly. Heart 1996; 76:507.
  33. Davies B, Bannister R, Sever P. Pressor amines and monoamine-oxidase inhibitors for treatment of postural hypotension in autonomic failure. Limitations and hazards. Lancet 1978; 1:172.
  34. Ghrist, DG, Brown, GE. Postural hypertension with syncope: Its successful treatment with ephedrine. Am J Med Sci 1928; 175:336.
  35. Biaggioni I, Onrot J, Stewart CK, Robertson D. The potent pressor effect of phenylpropanolamine in patients with autonomic impairment. JAMA 1987; 258:236.
  36. Kaufmann H, Brannan T, Krakoff L, et al. Treatment of orthostatic hypotension due to autonomic failure with a peripheral alpha-adrenergic agonist (midodrine). Neurology 1988; 38:951.
  37. Low PA, Gilden JL, Freeman R, et al. Efficacy of midodrine vs placebo in neurogenic orthostatic hypotension. A randomized, double-blind multicenter study. Midodrine Study Group. JAMA 1997; 277:1046.
  38. Ward CR, Gray JC, Gilroy JJ, Kenny RA. Midodrine: a role in the management of neurocardiogenic syncope. Heart 1998; 79:45.
  39. Izcovich A, González Malla C, Manzotti M, et al. Midodrine for orthostatic hypotension and recurrent reflex syncope: A systematic review. Neurology 2014; 83:1170.
  40. Parsaik AK, Singh B, Altayar O, et al. Midodrine for orthostatic hypotension: a systematic review and meta-analysis of clinical trials. J Gen Intern Med 2013; 28:1496.
  41. Hoeldtke RD, Streeten DH. Treatment of orthostatic hypotension with erythropoietin. N Engl J Med 1993; 329:611.
  42. Perera R, Isola L, Kaufmann H. Effect of recombinant erythropoietin on anemia and orthostatic hypotension in primary autonomic failure. Clin Auton Res 1995; 5:211.
  43. Onrot J, Goldberg MR, Biaggioni I, et al. Hemodynamic and humoral effects of caffeine in autonomic failure. Therapeutic implications for postprandial hypotension. N Engl J Med 1985; 313:549.
  44. Singer W, Sandroni P, Opfer-Gehrking TL, et al. Pyridostigmine treatment trial in neurogenic orthostatic hypotension. Arch Neurol 2006; 63:513.
  45. Shibao C, Okamoto LE, Gamboa A, et al. Comparative efficacy of yohimbine against pyridostigmine for the treatment of orthostatic hypotension in autonomic failure. Hypertension 2010; 56:847.
  46. Kochar MS, Itskovitz HD. Treatment of idiopathic orthostatic hypotension (Shy-Drager syndrome) with indomethacin. Lancet 1978; 1:1011.
  47. Mathias CJ, Fosbraey P, da Costa DF, et al. The effect of desmopressin on nocturnal polyuria, overnight weight loss, and morning postural hypotension in patients with autonomic failure. Br Med J (Clin Res Ed) 1986; 293:353.
  48. Kochar MS. Hemodynamic effects of lysine-vasopressin in orthostatic hypotension. Am J Kidney Dis 1985; 6:49.
  49. Onrot J, Goldberg MR, Biaggioni I, et al. Oral yohimbine in human autonomic failure. Neurology 1987; 37:215.
  50. Hoeldtke RD, Israel BC. Treatment of orthostatic hypotension with octreotide. J Clin Endocrinol Metab 1989; 68:1051.
  51. Jennings G, Esler M, Holmes R. Treatment of orthostatic hypotension with dihydroergotamine. Br Med J 1979; 2:307.
  52. Freeman R, Landsberg L. The treatment of orthostatic hypotension with dihydroxyphenylserine. Clin Neuropharmacol 1991; 14:296.
  53. Hauser RA, Hewitt LA, Isaacson S. Droxidopa in patients with neurogenic orthostatic hypotension associated with Parkinson's disease (NOH306A). J Parkinsons Dis 2014; 4:57.
  54. Kaufmann H, Saadia D, Voustianiouk A, et al. Norepinephrine precursor therapy in neurogenic orthostatic hypotension. Circulation 2003; 108:724.
  55. Mathias CJ, Senard JM, Braune S, et al. L-threo-dihydroxyphenylserine (L-threo-DOPS; droxidopa) in the management of neurogenic orthostatic hypotension: a multi-national, multi-center, dose-ranging study in multiple system atrophy and pure autonomic failure. Clin Auton Res 2001; 11:235.
  56. Kaufmann H, Freeman R, Biaggioni I, et al. Treatment of Neurogenic Orthostatic Hypotension with Droxidopa: Results from a Multi-Center, Double-Blind, Randomized, Placebo-Controlled, Parallel Group, Induction Design Study. Neurology 2012; 78:PL02.001.
  57. Biaggioni I, Freeman R, Mathias CJ, et al. Randomized withdrawal study of patients with symptomatic neurogenic orthostatic hypotension responsive to droxidopa. Hypertension 2015; 65:101.
  58. Lopes de Faria SR, Zanella MT, Andriolo A, et al. Peripheral dopaminergic blockade for the treatment of diabetic orthostatic hypotension. Clin Pharmacol Ther 1988; 44:670.
  59. Ramirez CE, Okamoto LE, Arnold AC, et al. Efficacy of atomoxetine versus midodrine for the treatment of orthostatic hypotension in autonomic failure. Hypertension 2014; 64:1235.
  60. Goldstein DS, Sewell L, Holmes C, et al. Temporary elimination of orthostatic hypotension by norepinephrine infusion. Clin Auton Res 2012; 22:303.
  61. Oldenburg O, Mitchell A, Nürnberger J, et al. Ambulatory norepinephrine treatment of severe autonomic orthostatic hypotension. J Am Coll Cardiol 2001; 37:219.
  62. Sandroni P, Benarroch EE, Wijdicks EF. Caudate hemorrhage as a possible complication of midodrine-induced supine hypertension. Mayo Clin Proc 2001; 76:1275.
  63. Kaufmann H. Primary autonomic failure: three clinical presentations of one disease? Ann Intern Med 2000; 133:382.
  64. Shannon J, Jordan J, Costa F, et al. The hypertension of autonomic failure and its treatment. Hypertension 1997; 30:1062.
  65. Jordan J, Shannon JR, Pohar B, et al. Contrasting effects of vasodilators on blood pressure and sodium balance in the hypertension of autonomic failure. J Am Soc Nephrol 1999; 10:35.
  66. van Kraaij DJ, Jansen RW, Bouwels LH, Hoefnagels WH. Furosemide withdrawal improves postprandial hypotension in elderly patients with heart failure and preserved left ventricular systolic function. Arch Intern Med 1999; 159:1599.
  67. Ong AC, Myint PK, Potter JF. Pharmacological treatment of postprandial reductions in blood pressure: a systematic review. J Am Geriatr Soc 2014; 62:649.
  68. Shibao C, Gamboa A, Diedrich A, et al. Acarbose, an alpha-glucosidase inhibitor, attenuates postprandial hypotension in autonomic failure. Hypertension 2007; 50:54.
  69. Alam M, Smith G, Bleasdale-Barr K, et al. Effects of the peptide release inhibitor, octreotide, on daytime hypotension and on nocturnal hypertension in primary autonomic failure. J Hypertens 1995; 13:1664.
  70. Heseltine D, Dakkak M, Woodhouse K, et al. The effect of caffeine on postprandial hypotension in the elderly. J Am Geriatr Soc 1991; 39:160.
  71. Lenders JW, Morre HL, Smits P, Thien T. The effects of caffeine on the postprandial fall of blood pressure in the elderly. Age Ageing 1988; 17:236.
  72. Rakic V, Beilin LJ, Burke V. Effect of coffee and tea drinking on postprandial hypotension in older men and women. Clin Exp Pharmacol Physiol 1996; 23:559.
  73. Lipsitz LA, Jansen RW, Connelly CM, et al. Haemodynamic and neurohumoral effects of caffeine in elderly patients with symptomatic postprandial hypotension: a double-blind, randomized, placebo-controlled study. Clin Sci (Lond) 1994; 87:259.
  74. Freeman R, Young J, Landsberg L, Lipsitz L. The treatment of postprandial hypotension in autonomic failure with 3,4-DL-threo-dihydroxyphenylserine. Neurology 1996; 47:1414.
  75. Jones KL, MacIntosh C, Su YC, et al. Guar gum reduces postprandial hypotension in older people. J Am Geriatr Soc 2001; 49:162.
  76. Russo A, Stevens JE, Wilson T, et al. Guar attenuates fall in postprandial blood pressure and slows gastric emptying of oral glucose in type 2 diabetes. Dig Dis Sci 2003; 48:1221.
  77. Jones KL, Tonkin A, Horowitz M, et al. Rate of gastric emptying is a determinant of postprandial hypotension in non-insulin-dependent diabetes mellitus. Clin Sci (Lond) 1998; 94:65.