# Postural Hypotension - Category: chronic - Review status: reviewed (every claim checked against a document named on this page) - Sources: ESC Guidelines for the diagnosis and management of syncope 2018 · Egyptian National Drug Formulary - Endocrine System 2024 (fludrocortisone monograph) · Bramox (midodrine) 5 mg tablets SmPC sections 4.2-4.4 (eMC product 2268) · Orthostatic Hypotension - StatPearls - NCBI Bookshelf - disease-level clinical article (postural-hypotension-full.txt) · DROXIDOPA capsules US prescribing information, boxed warning, section 1 Indications and Usage and section 2.1 Dosing Information (DailyMed SetID 1cefef7e-51b3-494c-946d-d5ae92bdc66a) - Verified date: 2026-08 ## Verified against - Bramox (midodrine) 5 mg tablets SmPC sections 4.2-4.4 (eMC product 2268) - Egyptian National Drug Formulary - Endocrine System 2024 (fludrocortisone monograph) - No dose - referral pathway, no medicine given in primary care - Orthostatic Hypotension - StatPearls - NCBI Bookshelf - disease-level clinical article (postural-hypotension-full.txt) - DROXIDOPA capsules US prescribing information, boxed warning, section 1 Indications and Usage and section 2.1 Dosing Information (DailyMed SetID 1cefef7e-51b3-494c-946d-d5ae92bdc66a) ## Treatment metadata - Midodrine — 2.5 mg — oral.solid - Referral & safety-netting (no drug therapy) - Fludrocortisone — 0.1 mg — oral.solid - Droxidopa — oral.solid ## Complete treatment card ```text POSTURAL HYPOTENSION Sources: ESC Guidelines for the diagnosis and management of syncope 2018 · Egyptian National Drug Formulary - Endocrine System 2024 (fludrocortisone monograph) · Bramox (midodrine) 5 mg tablets SmPC sections 4.2-4.4 (eMC product 2268) · Orthostatic Hypotension - StatPearls - NCBI Bookshelf - disease-level clinical article (postural-hypotension-full.txt) · DROXIDOPA capsules US prescribing information, boxed warning, section 1 Indications and Usage and section 2.1 Dosing Information (DailyMed SetID 1cefef7e-51b3-494c-946d-d5ae92bdc66a) Review status: REVIEWED against Bramox (midodrine) 5 mg tablets SmPC sections 4.2-4.4 (eMC product 2268), Egyptian National Drug Formulary - Endocrine System 2024 (fludrocortisone monograph), No dose - referral pathway, no medicine given in primary care, Orthostatic Hypotension - StatPearls - NCBI Bookshelf - disease-level clinical article (postural-hypotension- full.txt), DROXIDOPA capsules US prescribing information, boxed warning, section 1 Indications and Usage and section 2.1 Dosing Information (DailyMed SetID 1cefef7e-51b3-494c-946d-d5ae92bdc66a) (2026-08) IS IT THIS? - reference only, to read alongside your own examination SYMPTOMS - what the patient reports (11) - Trouble starts with a change of posture and eases off on sitting or lying down - Worse first thing in the morning, after exertion, in the heat, or when deconditioned - Usual complaints are lightheadedness, dizziness or a faint [dizziness · syncope] - Roughly a third of those affected report nothing at all - Blurred vision, gaps in the visual field, poor concentration, slowed thinking, weakness and fatigue [blurred vision · fatigue · poor concentration] - Repeated falls, unsteady gait and limb weakness are the less usual presentations - Breathlessness, from poor perfusion of the lung apices [breathlessness] - Chest pain, particularly where coronary artery disease coexists [chest pain] - Coathanger pain over the back of the neck and the shoulders - Acting out dreams, from loss of the normal REM sleep paralysis, points to a neurogenic cause [paralysis] - A drop within 2 hours of a big meal marks sympathetic failure SIGNS - what you find (5) - Supine hypertension: over 140 systolic or over 90 diastolic after 5 minutes lying flat [hypertension] - Supine hypertension accompanies roughly half of neurogenic cases [hypertension] - Tremor or muscle rigidity on examination calls for a full neurological assessment [tremor] - Bystanders may spot slowed thinking that the patient does not feel - Neurogenic cases carry other autonomic trouble: bladder dysfunction, constipation, erectile dysfunction [constipation · erectile dysfunction] TESTS (10) - Check orthostatic vitals routinely from age 60 upwards - Take standing blood pressure 1, 2 and 3 minutes after rising from a chair - The initial form is too quick for oscillometry to catch; the delayed form shows up beyond 3 minutes - Repeat the reading after eating or exercising as well - A pulse-change to pressure-change ratio under 0.5 bpm per mm Hg indicates a neurogenic cause - A pulse rise under 15 bpm favours a neurogenic cause; over 15 bpm favours a non-neurogenic one - Pulse response misleads on beta-blockers, on other rate-altering drugs, and in arrhythmia - Start the cardiac work-up with an ECG where heart disease is a risk - Bloods look for anaemia, dehydration, diabetes, alcohol use disorder and heart failure - Tilt table testing sorts all four types apart, and also vasovagal syncope and POTS IF NOT THIS - what else fits (12) - Vasovagal syncope - Postural tachycardia syndrome (POTS) - Carotid sinus syndrome - Anaemia (low haemoglobin) - Adrenal insufficiency - Cardiac arrhythmia - Congestive heart failure - Hyperglycaemia - Hypokalaemia - Myocardial infarction - Myocarditis - Phaeochromocytoma Source StatPearls "Orthostatic Hypotension" - disease-level clinical article Status traced to the source above Rx: Main treatment | Pressor alternative to midodrine - no Egyptian product registered MAIN TREATMENT - choose one 1. MIDODRINE [1st line] Adult 2.5 mg three times daily (during daytime hours), titrate up to 10 mg three times daily if needed - long-term Peds Specialist pediatric referral required Source Bramox (midodrine) 5 mg tablets SmPC sections 4.2-4.4 (eMC product 2268) Why Midodrine is an alpha-1 adrenergic agonist that constricts peripheral blood vessels to raise standing blood pressure; it is used when non-drug measures such as hydration, salt intake, and compression stockings are not enough to control postural hypotension. Caution First-line management is non-pharmacological (hydration 2-2.5 L/day, salt intake, waist- high compression stockings) and deprescribing offending antihypertensives/diuretics. CONTRAINDICATED in severe organic heart disease, acute renal disease, urinary retention, thyrotoxicosis, and pheochromocytoma. Avoid taking the last daily dose within 4 hours of bedtime to prevent severe supine hypertension; take doses during daytime upright hours. The last dose of the day goes at least four hours before bed. Midodrine taken late produces hypertension lying down, at night, which is the harm this drug actually causes. Measure the blood pressure both lying and standing, not standing alone. If supine hypertension appears and cutting the dose does not fix it, stop the drug. Ruled out by: severe heart disease, existing hypertension, acute or severe renal disease, prostatic obstruction or urinary retention, diabetic retinopathy, phaeochromocytoma, thyrotoxicosis, and narrow-angle glaucoma. Egypt MIDODRINE 2.5MG 20 TAB. EL NILE. 50.00 EGP (2.50/unit) MIDODRINE 1% ORAL DROPS 10ML EL NILE. 67.00 EGP -> ? strength differs, ? different route - not oral solid 2. REFERRAL & SAFETY-NETTING (NO DRUG THERAPY) [1st line] Adult Source No dose - referral pathway, no medicine given in primary care Why Carries the referral criteria and warning signs for this condition, which apply whichever treatment is chosen. Caution RED FLAG - Article caps fludrocortisone at no more than 0.2 mg/day due to heart failure, renal fibrosis, and hospitalization risk with long-term use; app's dosing range extends to 300 mcg (0.3 mg/day) Asymptomatic orthostatic hypotension usually needs no drug treatment at all, and causes such as hypovolaemia or cardiac failure may reverse once the underlying problem is corrected. The main harm of orthostatic hypotension is falls: it carries a high rate of morbidity and mortality, driven by frequent falls and repeated hospital admissions. In neurogenic cases the patient may be unaware of the low blood pressure, so an absence of dizziness does not rule out a dangerous drop - measure rather than rely on symptoms. Tremor or muscle rigidity found on examination should prompt a comprehensive neurological evaluation. Dream enactment behaviour - motor movements accompanying dreams, from loss of the normal atonia of REM sleep - points to a neurogenic cause and warrants neurological referral. About half of patients with neurogenic orthostatic hypotension also have supine hypertension, so check a lying blood pressure in every such patient, not only in those on pressor drugs. Initial bloods should look for anaemia, dehydration, diabetes, alcohol use disorder and heart failure as underlying causes. Reconcile the full medication list before anything else: vasodilators, diuretics, antidepressants, antipsychotics and dopaminergic drugs are all common precipitants, not just antihypertensives. Midodrine is indicated for orthostatic hypotension caused by autonomic dysfunction; its use in other types of orthostatic hypotension is off-label. Salt and fluid loading (up to 10 g of salt and 2 to 3 L of water daily) must be weighed against the patient's cardiac function and the risk of end-organ damage before it is advised. 3. FLUDROCORTISONE [2nd line] Adult 100 mcg (0.1 mg) once daily in the morning, titrate to 50-200 mcg daily based on response - long-term Peds Specialist use only Source Egyptian National Drug Formulary - Endocrine System 2024 (fludrocortisone monograph) Why Fludrocortisone is a synthetic mineralocorticoid that promotes renal sodium and water retention, expanding plasma volume to raise blood pressure; it serves as an alternative to midodrine for postural hypotension, at the cost of fluid retention and a tendency toward supine hypertension. Caution Monitor supine and standing blood pressure, and serum potassium regularly (high risk of hypokalemia and supine hypertension). Causes dose-dependent fluid retention and peripheral edema; keep the dose at or below 200 mcg daily in the elderly wherever possible. The 200 mcg (0.2 mg) daily ceiling is this indication's own - Orthostatic Hypotension - StatPearls - NCBI Bookshelf (NBK448192) sets it because prolonged use brings its own risks: heart failure, renal fibrosis, and more all-cause hospitalisation. The dose should not go above 0.2 mg/d. Egypt ASTONIN-H 0.1MG 30 TAB. AMOUN > MERCK... 18.00 EGP (0.60/unit) CORTILON 0.1 MG 20 TAB. AMOUN 16.00 EGP (0.80/unit) PRESSOR ALTERNATIVE TO MIDODRINE - NO EGYPTIAN PRODUCT REGISTERED 4. DROXIDOPA [2nd line] Adult 100 mg three times a day to start, titrated up. US label verbatim: "Starting dose is 100 mg three times during the day" and "Titrate by 100 mg three times daily, up to a maximum dose of 600 mg three times daily". Timing matters as much as the number - "To reduce the potential for supine hypertension, elevate the head of the bed and give the last dose at least 3 hours prior to bedtime" and "Take droxidopa capsule whole". - Reassessed rather than repeated indefinitely. US label verbatim: "Effectiveness beyond 2 weeks of treatment has not been established. The continued effectiveness of droxidopa capsules should be assessed periodically". Peds No paediatric dose is stated in the label used here. Neurogenic orthostatic hypotension in a child is a specialist neurology problem. Source DROXIDOPA capsules US prescribing information, boxed warning, section 1 Indications and Usage and section 2.1 Dosing Information (DailyMed SetID 1cefef7e-51b3-494c-946d-d5ae92bdc66a) Why The disease article places it alongside the drug already on the card, as the second pressor option for orthostatic hypotension: droxidopa is a precursor of norepinephrine, where midodrine works as an alpha-1 agonist. Droxidopa's effect wears off sooner than midodrine's and it may carry less long-term risk, and it particularly suits the patient whose peripheral sympathetic nerves have failed, shown by a low norepinephrine level. The US label's indication section names the same condition: dizziness and lightheadedness from neurogenic orthostatic hypotension in adults, whether due to primary autonomic failure (Parkinson's disease, multiple system atrophy, or pure autonomic failure), dopamine beta-hydroxylase deficiency, or non-diabetic autonomic neuropathy. Egypt registers no droxidopa product, so no brand or price can be shown; the row exists so a regimen already started abroad can be recognised and safely continued. Caution RED FLAG - boxed warning, supine hypertension. US label verbatim: "Monitor supine blood pressure prior to and during treatment and more frequently when increasing doses. Elevating the head of the bed lessens the risk of supine hypertension, and blood pressure should be measured in this position. If supine hypertension cannot be managed by elevation of the head of the bed, reduce or discontinue droxidopa capsules". Blood pressure is measured lying as well as standing, or the harm is invisible. The whole point of the drug is to raise standing pressure, and the risk is what it does to lying pressure overnight. Existing heart disease worsens on it. US label verbatim: "May exacerbate symptoms in patients with existing ischemic heart disease, arrhythmias, and congestive heart failure". Hyperpyrexia and confusion are listed label warnings - a febrile, confused patient on droxidopa needs the drug reviewed, not just an infection screen. Fludrocortisone, the volume-expanding option alongside it, has its own ceiling. The disease article sets it because prolonged use brings risks of its own - heart failure, renal fibrosis, and more all-cause hospitalisation - so the dose should not go above 0.2 mg/d. Egypt no Egyptian brand matched - prescribe by generic name Prices are indicative (dataset snapshot 2026-06); verify with the pharmacy. ``` --- Dawaa Reference is a reference for prescribers, not a medical device, and does not replace clinical judgement. [Privacy policy](/privacy)