What is the best approach to manage a 62-year-old female patient with Parkinson's disease (PD) who experiences fluctuating blood pressure, ranging from hypertension (elevated blood pressure) to orthostatic hypotension (low blood pressure)?

From the Guidelines

For a 62-year-old female with Parkinsonism experiencing blood pressure fluctuations, I strongly recommend a comprehensive management approach prioritizing non-pharmacological interventions and careful medication selection to minimize morbidity, mortality, and improve quality of life. The patient's condition is likely complicated by autonomic dysfunction, a common feature in Parkinsonism, which affects normal blood pressure regulation 1. Given the most recent and highest quality evidence from the 2024 ESC guidelines for the management of elevated blood pressure and hypertension, it is crucial to test for orthostatic hypotension before starting or intensifying BP-lowering medication 1. Non-pharmacological approaches should be the first-line treatment for orthostatic hypotension, including ensuring adequate salt intake, avoiding medications that aggravate hypotension, using compressive garments over the legs and abdomen, and encouraging physical activity and exercise to avoid deconditioning 1. Some key non-pharmacological interventions to consider are:

• Encouraging adequate hydration (1.5-2 liters daily)
• Wearing compression stockings
• Eating small, frequent meals to minimize postprandial hypotension
• Making gradual position changes
• Elevating the head of the bed by 30 degrees at night When pharmacological intervention is necessary, midodrine 2.5-10 mg three times daily (morning, noon, and mid-afternoon, not after 6 PM) can be beneficial in addressing hypotensive episodes, while a long-acting calcium channel blocker like amlodipine 5 mg daily can help manage hypertensive episodes 1. Regular monitoring and gradual medication adjustments are essential to avoid exacerbating either extreme. Consultation with a neurologist specializing in movement disorders is also recommended to optimize the patient's Parkinson's medication regimen, as some antiparkinsonian drugs can contribute to blood pressure instability 1.

From the FDA Drug Label

Midodrine has been studied in 3 principal controlled trials, one of 3-weeks duration and 2 of 1 to 2 days duration. All studies were randomized, double-blind and parallel-design trials in patients with orthostatic hypotension of any etiology and supine-to-standing fall of systolic blood pressure of at least 15 mmHg accompanied by at least moderate dizziness/lightheadedness Patients with pre-existing sustained supine hypertension above 180/110 mmHg were routinely excluded. In a 3-week study in 170 patients, most previously untreated with midodrine, the midodrine-treated patients (10 mg t.i.d., with the last dose not later than 6 P.M.) had significantly higher (by about 20 mmHg) 1-minute standing systolic pressure 1 hour after dosing (blood pressures were not measured at other times) for all 3 weeks Supine and sitting blood pressure rose 16/8 and 20/10 mmHg, respectively, on average In a 1-day, dose-response trial, single doses of 0,2. 5,10 and 20 mg of midodrine were given to 25 patients. The 10 and 20 mg doses produced increases in standing 1-minute systolic pressure of about 30 mmHg at 1 hour; the increase was sustained in part for 2 hours after 10 mg and 4 hours after 20 mg. Supine systolic pressure was ≥200 mmHg in 22% of patients on 10 mg and 45% of patients on 20 mg; elevated pressures often lasted 6 hours or more

The patient has elevated blood pressure between systolic 160-190 and hypotensive blood pressure between systolic 80-90’s.

• The midodrine label warns about excluding patients with pre-existing sustained supine hypertension above 180/110 mmHg.
• The patient's elevated blood pressure is close to this threshold, and midodrine may further increase supine systolic pressure.
• Given the patient's Parkinsonism and blood pressure fluctuations, it is crucial to carefully consider the potential risks and benefits of midodrine treatment.
• The patient's hypotensive episodes may be addressed with midodrine, but the potential for worsening hypertension must be carefully monitored 2.
• It is essential to weigh the benefits of midodrine in treating orthostatic hypotension against the potential risks of exacerbating hypertension in this patient.

From the Research

Blood Pressure Management in Parkinson's Disease

The patient's condition of having elevated blood pressure between systolic 160-190 and hypotensive blood pressure between systolic 80-90's is not uncommon in Parkinson's disease patients.

• Orthostatic hypotension (OH) is a common non-motor feature of Parkinson's disease, which may cause unexplained falls, syncope, lightheadedness, cognitive impairment, dyspnea, fatigue, blurred vision, shoulder, neck, or low-back pain upon standing 3.
• About 50% of patients with neurogenic OH also suffer from supine and nocturnal hypertension, which should be monitored for with in-office, home and 24 h-ambulatory BP measurements 3.
• Abnormal blood pressure profiles are commonly encountered in patients with Parkinson's disease, including high blood pressure, orthostatic hypotension, supine hypertension, and nocturnal hypertension 4.

Treatment and Management

• The correction of non-neurogenic causes and exacerbating factors, lifestyle changes and non-pharmacological measures are the cornerstone of OH treatment 3.
• If these measures fail, pharmacological interventions (sympathomimetic agents and/or fludrocortisone) should be introduced stepwise depending on the severity of symptoms 3.
• Non-pharmacological management measures, such as health education, dietary adjustments, exercise, and Chinese medicine techniques, can improve patients' symptoms and quality of life 5.
• Supine hypertension sometimes requires treatment, and a set of arguments suggests that it can be induced or worsened by antihypotensive drugs 6.

Clinical Implications

• Blood pressure dysregulation in patients with Parkinson's disease has several implications in clinical practice and presents an ongoing concern 7.
• If left untreated, hypertension may lead to cardiovascular disease whereas hypotension may lead to fall-related complications, with tremendous impact on the quality of life of affected individuals 7.
• The effect of blood pressure control and the risk of death from cardiovascular disease in Parkinson disease are largely unexplored, and further research is warranted to clarify the mechanisms, clinical implications, and potential reversibility of compromised cardiovascular function 7.