Management of Orthostatic Hypotension

Jose-Alberto Palma, MD, PhD; Horacio Kaufmann, MD, FAAN Autonomic Disorders p. 154-177 February 2020, Vol.26, No.1 doi: 10.1212/CON.0000000000000816
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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 first-line 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.

Address correspondence to Dr Horacio Kaufmann, NYU Langone Health, 530 First Ave, Suite 9Q–Dysautonomia Center, New York, NY 10016, [email protected].

RELATIONSHIP DISCLOSURE: Dr Palma serves as managing editor for Clinical Autonomic Research and as a consultant for Biogen, Dr Reddy’s Laboratories Ltd, Lundbeck, and PTC Therapeutics. Dr Palma receives research/grant support from the Familial Dysautonomia Foundation, Inc; the Michael J. Fox Foundation for Parkinson’s Research; the Multiple System Atrophy Coalition; and the National Institute of Neurological Disorders and Stroke (R01NS107596, U54NS065736). Dr Kaufmann serves as editor-in-chief of Clinical Autonomic Research and as a consultant for and on the scientific advisory boards of Biogen, Biohaven Pharmaceuticals, Lundbeck, and Pfizer Inc. Dr Kaufmann receives research/grant support from the Familial Dysautonomia Foundation, Inc; the Michael J. Fox Foundation for Parkinson's Research; the Multiple System Atrophy Coalition; the National Institutes of Health (R01HL103988, U54NS065736); Theravance Biopharma; and the US Food and Drug Administration (FDR3731-01) and publishing royalties from UpToDate, Inc. Dr Kaufmann has served as an expert witness for the Department of Justice regarding the alleged relationship between human papilloma virus vaccination and autonomic disorders.

UNLABELED USE OF PRODUCTS/INVESTIGATIONAL USE DISCLOSURE: Drs Palma and Kaufmann discuss the unlabeled/investigational use of acarbose, ampreloxetine, atomoxetine, erythropoietin, fludrocortisone, octreotide, and pyridostigmine for the treatment of orthostatic hypotension.

© 2020 American Academy of Neurology.