From the Guidelines
Management of orthostatic hypotension in patients with Parkinson's disease (PD) involves a combination of non-pharmacological and pharmacological strategies.
Non-Pharmacological Strategies
- Acute water ingestion can provide temporary relief, with a pressor effect occurring 30 minutes after ingestion of ≥240 mL of water 1
- Physical counter-pressure maneuvers, such as leg crossing, lower body muscle tensing, and maximal force handgrip, can increase blood pressure 1
- Compression garments, at least thigh high and preferably including the abdomen, can improve orthostatic symptoms and blunt associated decreases in blood pressure 1
- Increased salt and fluid intake may be reasonable in selected patients, with salt supplementation (6 to 9 g per day) and water ingestion increasing plasma volume and blood pressure 1
- Lifestyle modifications, such as sleeping with the head of the bed elevated, can help prevent nocturnal polyuria and maintain a favorable distribution of body fluids 1
Pharmacological Strategies
- Midodrine can improve symptoms of orthostatic hypotension, with a dose-dependent effect, but may be limited by supine hypertension 1
- Droxidopa can improve symptoms of neurogenic orthostatic hypotension, but may be limited by supine hypertension, headache, dizziness, and nausea 1
- Fludrocortisone can increase plasma volume and improve symptoms of orthostatic hypotension, but may be limited by supine hypertension, edema, hypokalemia, and headache 1
- Pyridostigmine may be beneficial in patients refractory to other treatments, with improvements in orthostatic tolerance through increases in peripheral vascular resistance and blood pressure 1
- Octreotide may be beneficial in patients with refractory recurrent postprandial or neurogenic orthostatic hypotension, by reducing splanchnic blood flow and preventing postprandial hypotension 1
From the Research
Management Strategies for Orthostatic Hypotension in Parkinson's Disease
- Non-pharmacological approaches are recommended as the first line of treatment, including patient education and lifestyle modifications 2, 3
- Pharmacological treatments may be necessary for symptomatic patients who do not respond to non-pharmacological management, with options including:
- Treatment strategies should be individualized and take into account the patient's specific needs and comorbidities 5
- The goal of treatment is to reduce postural symptoms and improve quality of life, rather than solely focusing on blood pressure readings 3
- Emerging therapies, such as norepinephrine transporter inhibitors, are being investigated for the treatment of orthostatic hypotension in Parkinson's disease 4