Droxidopa for refractory neurogenic orthostatic hypotension in amyloid light chain amyloidosis

Abstract

Neurogenic orthostatic hypotension (nOH) secondary to amyloidosis is a rare condition associated with significant blood pressure (BP) drops and problematic symptoms for patients. There is limited literature on the management of nOH secondary to amyloidosis. In this report, we describe a case on a 60-year-old female with an extensive past medical history, including amyloidosis, pulmonary hypertension, heart failure with preserved ejection fraction, and episodic hypotension, who presents to the hospital with dizziness and home systolic BP readings in the 80s. Due to hypoperfusion, she eventually developed acute kidney failure and was transferred to the intensive care unit (ICU) for intermittent continuous renal replacement therapy with pressor support using norepinephrine. She had difficulty maintaining adequate BPs while on midodrine, so fludrocortisone, followed by pseudoephedrine, were added to improve her pressures. She was subsequently transferred out of the ICU, but her BPs still remained low, and she was not able to sit up without getting dizzy. Droxidopa was eventually added on to help treat her refractory nOH. After droxidopa initiation, her BPs improved and she was able to sit up without dizziness and was finally discharged home. This case report demonstrates the therapeutic usefulness of droxidopa in improving both BPs and symptoms in refractory nOH secondary to amyloidosis.