What is the recommended dosing for Northera (droxidopa) in treating neurogenic orthostatic hypotension (NOH)?

Recommended Dosing for Northera (Droxidopa) in Neurogenic Orthostatic Hypotension

The recommended dosing for Northera (droxidopa) is to start at 100 mg three times daily, taken upon waking, at midday, and in late afternoon (at least 3 hours before bedtime), with titration in 100 mg increments every 24-48 hours based on symptomatic response, up to a maximum dose of 600 mg three times daily. 1

Initial Dosing and Administration

• Start with 100 mg three times daily
• Administer at specific times:
  • Upon arising in the morning
  • At midday
  • In late afternoon (at least 3 hours before bedtime to reduce risk of supine hypertension)
• Take consistently with or without food
• Swallow capsules whole

Titration Protocol

• Increase dose in increments of 100 mg three times daily
• Allow 24-48 hours between dose increases
• Titrate to symptomatic response
• Maximum dose: 600 mg three times daily (1,800 mg total daily dose)
• Monitor supine blood pressure before and after each dose increase

Monitoring Requirements

• Check supine blood pressure prior to initiating therapy
• Monitor blood pressure after each dose increase
• Measure blood pressure in both supine and standing positions
• Elevate head of bed to reduce risk of supine hypertension
• Assess continued effectiveness periodically, as effectiveness beyond 2 weeks has not been established in clinical trials 1

Special Considerations

• Patients with Parkinson's disease: Be aware that carbidopa may decrease droxidopa effectiveness 2
• Elderly patients: Consider starting at lower doses 3
• Missed doses: Take the next scheduled dose (do not double up) 1

Potential Side Effects to Monitor

• Supine hypertension (most serious concern)
• Headache (reported in 7.4% of patients)
• Dizziness (reported in 3.7% of patients)
• Falls (reported in 17% of patients in longer-term studies) 4
• Potential exacerbation of existing cardiac conditions 1

Evidence for Efficacy

• Droxidopa has been shown to improve symptoms of neurogenic OH in patients with Parkinson's disease, multiple system atrophy, and pure autonomic failure 2
• Clinical trials demonstrated significant improvement in dizziness/lightheadedness symptoms and standing systolic blood pressure compared to placebo 5
• Open-label extension data suggests potential benefit beyond the 2-week period established in initial trials 4

Common Pitfalls to Avoid

1. Administering doses too close to bedtime, increasing risk of supine hypertension
2. Inadequate monitoring of supine blood pressure
3. Failure to elevate the head of the bed when resting or sleeping
4. Not assessing continued effectiveness periodically
5. Overlooking potential interactions with other medications, particularly in patients with Parkinson's disease taking carbidopa

Algorithm for Dose Adjustment

1. Start at 100 mg three times daily
2. After 24-48 hours, assess:
   • Symptomatic improvement
   • Standing blood pressure
   • Presence of side effects
3. If inadequate response and no concerning side effects:
   • Increase by 100 mg three times daily
   • Reassess after 24-48 hours
4. Continue titration until:
   • Adequate symptom control achieved, OR
   • Maximum dose of 600 mg three times daily reached, OR
   • Intolerable side effects occur
5. Once optimal dose is established, maintain and reassess effectiveness periodically

Remember that the FDA label notes effectiveness beyond 2 weeks has not been established in the initial trials, though more recent research suggests potential longer-term benefit 4.