Droxidopa for Neurogenic Orthostatic Hypotension (NOH)
The recommended treatment for neurogenic orthostatic hypotension is droxidopa at an initial dose of 100 mg three times daily, titrated up to a maximum of 600 mg three times daily (maximum total daily dose of 1,800 mg), with doses taken upon waking, at midday, and in late afternoon at least 3 hours before bedtime. 1, 2
Dosing Protocol
- Starting dose: 100 mg three times daily 1, 2
- Titration: Increase by 100 mg three times daily every 24-48 hours 2
- Maximum dose: 600 mg three times daily (total daily dose: 1,800 mg) 1, 2
- Timing: Take upon arising in morning, at midday, and late afternoon (at least 3 hours before bedtime) 2
- Administration: Take consistently either with or without food; swallow capsules whole 2
Monitoring and Safety Considerations
- Blood pressure monitoring: Check supine blood pressure before initiating treatment and after each dose increase 2
- Supine hypertension: Elevate head of bed during sleep to reduce risk 1, 2
- Cardiac patients: Use with caution in patients with ischemic heart disease, arrhythmias, or congestive heart failure 1, 2
- Effectiveness assessment: Regularly evaluate continued effectiveness beyond 2 weeks of treatment 2
Efficacy
- Droxidopa improves orthostatic symptoms such as dizziness and lightheadedness 1
- Increases standing systolic blood pressure by approximately 11.2 mmHg compared to 3.9 mmHg with placebo 1, 3
- Improves activities of daily living for patients with NOH 4
Common Side Effects
Special Considerations
- Patients with Parkinson's disease taking carbidopa may experience decreased droxidopa effectiveness 1
- Droxidopa may be poorly tolerated in patients with heart failure 6, 1
- For patients with renal impairment, dosing recommendations cannot be provided for those with GFR less than 30 mL/min 2
Alternative Treatments
If droxidopa is ineffective or contraindicated, consider:
- Midodrine (2.5-10 mg three times daily)
- Fludrocortisone (0.1-1.0 mg daily)
- Pyridostigmine (30-60 mg 2-3 times daily) - may be better tolerated in patients with cardiac involvement 6, 1
Non-Pharmacological Measures
- Compression garments
- Increased salt and fluid intake
- Physical counter-maneuvers
- Elevating head of bed during sleep 6, 1
Always monitor for supine hypertension, which is the most significant safety concern with droxidopa treatment. If supine hypertension cannot be managed by elevation of the head of bed, reduce or discontinue droxidopa to minimize cardiovascular risk, particularly stroke 2.