Initiating droxidopa for neurogenic orthostatic hypotension in a patient with Parkinson disease

Claassen, Daniel O.; Lew, Mark F.

doi:10.1007/s10286-017-0429-3

Cited by 7 publications

(5 citation statements)

References 5 publications

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“…To identify the best dose for each patient, supervised titration by a clinician is recommended. 79,80 Although in clinical trials droxidopa was administered 3 times a day, clinical experience shows that the dose of droxidopa should be individualized to each patient's needs, taking into account when the patient is standing and active. For example, in a patient with a movement disorder and orthostatic hypotension who is active for only a few hours in the morning (eg, showering, preparing breakfast), it is reasonable to use a single morning droxidopa dose and skip the afternoon and evening doses.…”

Section: Droxidopamentioning

confidence: 99%

Management of Orthostatic Hypotension

Palma¹

2020

CONTINUUM: Lifelong Learning in Neurology

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PURPOSE OF REVIEW:This article reviews the management of orthostatic hypotension with emphasis on neurogenic orthostatic hypotension.RECENT FINDINGS: Establishing whether the cause of orthostatic hypotension is a pathologic lesion in sympathetic neurons (ie, neurogenic orthostatic hypotension) or secondary to other medical causes (ie, non-neurogenic orthostatic hypotension) can be achieved by measuring blood pressure and heart rate at the bedside. Whereas fludrocortisone has been extensively used as firstline treatment in the past, it is associated with adverse events including renal and cardiac failure and increased risk of all-cause hospitalization. Distinguishing whether neurogenic orthostatic hypotension is caused by central or peripheral dysfunction has therapeutic implications. Patients with peripheral sympathetic denervation respond better to norepinephrine agonists/precursors such as droxidopa, whereas patients with central autonomic dysfunction respond better to norepinephrine reuptake inhibitors. SUMMARY:Management of orthostatic hypotension is aimed at improving quality of life and reducing symptoms rather than at normalizing blood pressure. Nonpharmacologic measures are the key to success. Pharmacologic options include volume expansion with fludrocortisone and sympathetic enhancement with midodrine, droxidopa, and norepinephrine reuptake inhibitors. Neurogenic supine hypertension complicates management of orthostatic hypotension and is primarily ameliorated by avoiding the supine position and sleeping with the head of the bed elevated.

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Section: Droxidopamentioning

confidence: 99%

Management of Orthostatic Hypotension

Palma¹

2020

CONTINUUM: Lifelong Learning in Neurology

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“…Droxidopa is not approved in Europe. Extensive clinical experience shows that droxidopa is safe and well tolerated . Peak plasma concentrations of droxidopa are reached ∼3 hours after oral administration.…”

Section: Cardiovascular Autonomic Dysfunctionmentioning

confidence: 99%

Treatment of autonomic dysfunction in Parkinson disease and other synucleinopathies

2018

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Dysfunction of the autonomic nervous system afflicts most patients with Parkinson disease and other synucleinopathies such as dementia with Lewy bodies, multiple system atrophy, and pure autonomic failure, reducing quality of life and increasing mortality. For example, gastrointestinal dysfunction can lead to impaired drug pharmacodynamics causing a worsening in motor symptoms, and neurogenic orthostatic hypotension can cause syncope, falls, and fractures. When recognized, autonomic problems can be treated, sometimes successfully. Discontinuation of potentially causative/aggravating drugs, patient education, and nonpharmacological approaches are useful and should be tried first. Pathophysiology-based pharmacological treatments that have shown efficacy in controlled trials of patients with synucleinopathies have been approved in many countries and are key to an effective management. Here, we review the treatment of autonomic dysfunction in patients with Parkinson disease and other synucleinopathies, summarize the nonpharmacological and current pharmacological therapeutic strategies including recently approved drugs, and provide practical advice and management algorithms for clinicians, with focus on neurogenic orthostatic hypotension, supine hypertension, dysphagia, sialorrhea, gastroparesis, constipation, neurogenic overactive bladder, underactive bladder, and sexual dysfunction. © 2018 International Parkinson and Movement Disorder Society.

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“…Extensive clinical experience shows that droxidopa is safe and well tolerated. [69][70][71][72][73][74][75][76][77] Peak plasma concentrations of droxidopa are reached ~3-h after oral administration. The dosage used in clinical trials was 100-600 mg three times/day although clinical experience indicates that the dosage should be tailored to each patient's needs considering the periods of time when he/she is going to be active or inactive.…”

Section: Droxidopamentioning

confidence: 99%

Orthostatic Hypotension in Parkinson Disease

Palma

2020

Clinics in Geriatric Medicine

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neurons are also affected. 7,8 Autonomic dysfunction in synucleinopathies occurs at all stages of the disease and occasionally is its only manifestation. 9Among the most debilitating manifestations of autonomic dysfunction in PD is orthostatic hypotension (OH), which is a sustained fall in blood pressure (BP) on standing. The current definition of OH, based on expert consensus, 10 is a fall of at least 20 mmHg in systolic BP or 10 mmHg in diastolic BP within 3 minutes of standing or upright tilt. OH can impair perfusion to organs above the heart, most notably the brain, resulting in symptoms of tissue hypoperfusion. Symptoms can be very disabling, have a profound impact on a patient's quality of life, and increase morbidity and mortality. 11,12 In PD and other synucleinopathies, OH is neurogenic (nOH), i.e., due to reduced norepinephrine release from postganglionic efferent sympathetic nerves, resulting in defective vasoconstriction when assuming the upright posture (Figure 1). 10 Complicating nOH management is arterial hypertension when supine (SH), which occurs in up to 50% of patients with efferent baroreflex failure. 13,14 When recognized, nOH can be treated, sometimes successfully. Discontinuation of potentially causative/aggravating drugs, patient education, non-pharmacological approaches, and pathophysiology-based drug therapy are key to an effective management.Here we review the epidemiology, evaluation, and management of nOH, with emphasis on patients with PD, summarize the non-pharmacologic and pharmacologic treatment strategies, and provide practical advice on the management of patients with this debilitating condition.

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Initiating droxidopa for neurogenic orthostatic hypotension in a patient with Parkinson disease

Cited by 7 publications

References 5 publications

Management of Orthostatic Hypotension

Management of Orthostatic Hypotension

Treatment of autonomic dysfunction in Parkinson disease and other synucleinopathies

Orthostatic Hypotension in Parkinson Disease

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