Can Diovan (Valsartan) and Midodrine be combined in patients with Parkinson's disease and hypertension who experience significant orthostatic hypotension?

From the Guidelines

Combining Diovan (valsartan) and midodrine in hypertensive Parkinson's patients with significant orthostatic hypotension can be beneficial, but requires careful management to avoid adverse effects such as supine hypertension. This combination can be beneficial as the medications work through different mechanisms - Diovan blocks angiotensin II receptors to lower blood pressure while midodrine is an alpha-1 agonist that increases blood pressure by constricting blood vessels. For implementation, consider starting with low doses of both medications and titrating slowly. Diovan should typically be administered once daily in the morning (starting at 40-80mg), while midodrine is usually given in divided doses (2.5-10mg, 2-3 times daily), avoiding evening doses to prevent supine hypertension, as suggested by the 2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope 1. Blood pressure monitoring in both supine and standing positions is essential, with target parameters being to maintain adequate standing blood pressure without causing excessive supine hypertension. The timing of doses relative to meals and Parkinson's medications may need adjustment to optimize effectiveness. This approach addresses both the baseline hypertension and the orthostatic component, but requires vigilant monitoring for adverse effects including excessive hypertension when lying down, especially at night. Additionally, other treatments such as fludrocortisone, droxidopa, and pyridostigmine may be beneficial in patients with neurogenic orthostatic hypotension, as noted in the 2017 guideline 1. However, the combination of Diovan and midodrine is not explicitly mentioned in the provided studies, but based on their mechanisms of action and the guidance from the 2017 ACC/AHA/HRS guideline, it can be considered a viable option for managing orthostatic hypotension in hypertensive Parkinson's patients. It's also important to consider the potential interactions between these medications and other treatments for Parkinson's disease, as well as the patient's overall health status and medical history. In terms of specific guidance, the seventh report of the joint national committee on prevention, detection, evaluation, and treatment of high blood pressure 1 provides information on combination therapies for hypertension, but does not specifically address the use of Diovan and midodrine together. Therefore, the decision to combine these medications should be made on a case-by-case basis, taking into account the individual patient's needs and medical status. Key considerations include:

• Starting with low doses and titrating slowly
• Monitoring blood pressure in both supine and standing positions
• Avoiding evening doses of midodrine to prevent supine hypertension
• Adjusting the timing of doses relative to meals and Parkinson's medications
• Vigilant monitoring for adverse effects, including excessive hypertension when lying down.

From the Research

Combination of Diovan (Valsartan) and Midodrine in Patients with Parkinson's Disease and Hypertension

• There is no direct evidence to suggest that Diovan (Valsartan) and Midodrine can be combined in patients with Parkinson's disease and hypertension who experience significant orthostatic hypotension 2, 3.
• Midodrine is a commonly used medication for the treatment of orthostatic hypotension, and it has received FDA approval for this indication 3.
• The use of midodrine in patients with Parkinson's disease and orthostatic hypotension is supported by several studies, which suggest that it can be effective in improving blood pressure and reducing symptoms of orthostatic hypotension 3, 4.
• However, the combination of midodrine with other medications, such as Diovan (Valsartan), which is an angiotensin II receptor antagonist used to treat hypertension, has not been specifically studied in the context of Parkinson's disease and orthostatic hypotension.
• The management of orthostatic hypotension in patients with Parkinson's disease requires a patient-specific approach, taking into account the individual's underlying medical conditions, medications, and symptoms 2, 5.
• The treatment of orthostatic hypotension in patients with Parkinson's disease should be tailored to the individual patient's needs, and may involve the use of non-pharmacological strategies, such as increasing fluid and salt intake, as well as pharmacological treatments, such as midodrine and other medications 3, 6.