Full List of Medications - Grouped By What They Do

There are numerous medications available to treat orthostatic intolerance. This list breaks them down by what they do, what part of the orthostatic problem they address. Some are commonly used. Others are used for specific conditions or when the symptoms are not responding to other treatments.

 

Medications that increase blood volume

• Fludrocortisone (Florinef)
• Oral contraceptive pills
• Clonidine
• Vasopressin- Desmopressin – DDAVP (Can be used to supplement volume expansion & reduce nocturnal diuresis)³
• Erythropoeitin (EPO) (also increases red blood cell mass and may cause constriction of the vessels)

Medications that interfere with the release of or response to epinephrine and norepinephrine

• Beta-blockers (e.g., atenolol, propranolol, metoprolol, labetalol)
  • Pindolol has partial agonist activity. It is reported to be useful in some patients, especially those with very low supine norepinephrine concentrations.²
• Disopyramide (Norpace)
• Use for vasovagal syncope – not established
• Angiotensin converting enzyme inhibitors/angiotensin receptor blockers ¹¹

Medications that improve vasoconstriction

• Stimulants: (e.g., methylphenidate [Ritalin] or dextroamphetamine [Dexedrine])
• Midodrine (Proamatine)
• Modafanil (Provigil)
• Selective serotonin reuptake inhibitors (SSRI) and SNRI (see lists in tabs below for their names) These medications may also affect the central nervous system reflex pathways in NMH as well. ¹
• Pseudoephedrine (Sudafed) (Ephedrine) (These drugs were used more in the past. They are generally not used now because of their many effects and side effects. (Do Not take within 4 hours before sleep. Side Effects: supine high blood pressure, tachycardia, central nervous system side effect -e.g. anxiety, tremulousness.
• Phenylephrine
• Clonidine
• Yohimbe (Herb)

Control heart rate increase

• Pyridostigmine bromide

Somatostatin analogues

• Somatostatin^{1, 2} 
• Octreotide²
  

  Octreotide has been used to reduce the low blood pressure after eating (postprandial hypotension). Octreotide is a splanchnic vasoconstrictor, it constricts (narrows) the vessels in the intestinal areas. This decreases the splanchnic pooling that follows eating. When they are both taken, Midodrine and Octreotide have synergistic pressor effects - they work differently and are more effective together. The 2 drugs act by different mechanisms as they affect different vascular beds. These agents might also be useful in managing vasovagal faint due to splanchnic hypervolemia during orthostatic stress.

Prevent the veins from dilating (getting larger so they hold more blood)

• Nonsteroidal Anti-Inflammatory Drugs(NSAID) (Ibuprofen,Indomethacin) This use is controversial.^{2, 13}
• Blocks dopamine receptor: metoclopramide (Reglan), domperidone (Motilium)¹³ (These are used for GI symptoms and not generally used for orthostatic problems)
• Beta-2 adrenoceptor blockade (propranolol)¹³

Increase cardiac output (how much blood the heart pumps out with each beat)

• Beta blockers with sympathomimetic activity adrenoceptor blockade (pindolol)¹³

Prevent postprandial hypotension (Low blood pressure after eating)

• Somatostain analogue: octreotide¹³
• Caffeine (adenosine receptor blockade)¹³

Antihistamines

• Used in mastocytosis and occasionally in dysautonomia from diabetes.²

Others

• Hydralazine²
 
• Ergotamine - constriction of the veins^{2, 13}