title: The Treatment of Primary Orthostatic Hypotension.
abstract: OBJECTIVE
  To review the efficacy and safety of pharmacological and nonpharmacological strategies used to treat primary orthostatic hypotension (OH).
  
  
  METHODS
  A literature review using PubMed and MEDLINE databases searching hypotension, non-pharmacological therapy, midodrine, droxidopa, pyridostigmine, fludrocortisone, atomoxetine, pseudoephedrine, and octreotide was performed.
  
  
  METHODS
  Randomized or observational studies, cohorts, case series, or case reports written in English between January 1970 and November 2016 that assessed primary OH treatment in adult patients were evaluated.
  
  
  RESULTS
  Based on the chosen criteria, it was found that OH patients make up approximately 15% of all syncope patients, predominantly as a result of cardiovascular or neurological insults, or offending medication. Nonpharmacological strategies are the primary treatment, such as discontinuing offending medications, switching medication administration to bedtime, avoiding large carbohydrate-rich meals, limiting alcohol, maintaining adequate hydration, adding salt to diet, and so on. If these fail, pharmacotherapy can help ameliorate symptoms, including midodrine, droxidopa, fludrocortisone, pyridostigmine, atomoxetine, sympathomimetic agents, and octreotide.
  
  
  CONCLUSIONS
  Midodrine and droxidopa possess the most evidence with respect to increasing blood pressure and alleviating symptoms. Pyridostigmine and fludrocortisone can be used in patients who fail to respond to these agents. Emerging evidence with low-dose atomoxetine is promising, especially in those with central autonomic failure, and may prove to be a viable alternative treatment option. Data surrounding other therapies such as sympathomimetic agents or octreotide are minimal. Medication management of primary OH should be guided by patient-specific factors, such as tolerability, adverse effects, and drug-drug and drug-disease interactions.
authors.affiliation: 1 Nova Southeastern University College of Pharmacy, Palm Beach Gardens, FL, USA.
authors.forename: Genevieve M
authors.initials: GM
authors.lastname: Hale
authors.affiliation: 1 Nova Southeastern University College of Pharmacy, Palm Beach Gardens, FL, USA.
authors.forename: Jose
authors.initials: J
authors.lastname: Valdes
authors.affiliation: 2 VA Ann Arbor Healthcare System, Ann Arbor, MI, USA.
authors.forename: Michael
authors.initials: M
authors.lastname: Brenner
mesh_terms: D000328:Adult; D000069445:Atomoxetine Hydrochloride / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use*; D001794:Blood Pressure / Q000187:drug effects*; D002986:Clinical Trials as Topic; D004305:Dose-Response Relationship, Drug; D015103:Droxidopa / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use*; D004347:Drug Interactions; D005081:Exercise Therapy; D006801:Humans; D007024:Hypotension, Orthostatic / Q000139:chemically induced / Q000188:drug therapy*; D008879:Midodrine / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use*; D011187:Posture; D016896:Treatment Outcome
chemical_list: D000069445:Atomoxetine Hydrochloride; D008879:Midodrine; D015103:Droxidopa
keywords: alternative medicine/therapies; cardiology; cardiovascular drugs; clinical practice; neurology; neuropharmacology