Sunday, August 14, 2022

Treatment Of Orthostatic Hypotension In Parkinson’s Disease

Blood Pressure And Parkinsons: Whats The Connection

Parkinson’s Disease and Neurogenic Orthostatic Hypotension

This 60-minute audio with slides is an interview of two neurologists and a person with Parkinsons discussing the symptoms, causes, and how to mitigate episodes of low blood pressure, as well as high blood pressure and recent Phase III trial testing of the high blood pressure medication, isradipine, to slow Parkinsons disease progression without lowering blood pressure too much.

Understanding Blood Pressure Fluctuations In Parkinson’s Disease

In this 1-hour webinar Anindita Deb, MD, Movement Disorder Specialist, provides an overview of the human nervous system, which controls blood pressure, before explaining what orthostatic hypotension is, how to monitor nOH, medications that can affect blood pressure, lifestyle changes to improve nOH, how nOH affects cognition and mobility. She then spends considerable time sharing physical maneuvers and medications to treat nOH before answering listener questions.

Whats Hot In Pd If You Are Dizzy Or Passing Out It Could Be Your Parkinsons Disease Or Parkinsons Disease Medications

This 3-page article, with references, is a personal statement by Dr. Okun describing the mis-diagnoses Parkinsons patients can be given when visiting the ER for symptoms of dizziness or syncope outlining what defines a proper diagnosis of orthostatic hypotension, its frequency in people with Parkinsons, medication and lifestyle changes that can help.

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Preventing And Treating Orthostatic Hypotension: As Easy As A B C

Drug therapy alone is never adequate to treat orthostatic hypotension. A patient-oriented approach that emphasizes education and nonpharmacologic strategies is critical. This article provides easy-to-remember management recommendations, using a combination of drug and non-drug treatments that have proven effective.

Living With Postural Hypotension

Neurogenic orthostatic hypotension and supine hypertension in Parkinson ...

This 7-page fact sheet was developed for people affected by MSA, but is just as useful to those with Parkinsons disease, who are experiencing drops in blood pressure and postural hypotension. It covers symptoms, when they are likely to happen, what to do, exercise and other tips for daily living with OH, including medication options.

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Orthostatic Hypotension: A Prodromal Marker Of Parkinson’s Disease

Department of Epidemiology, Erasmus MC University Medical Center, Rotterdam, the Netherlands

Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands

Francesco U.S. Mattace Raso PhD

Department of Geriatric Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands

Department of Epidemiology, Erasmus MC University Medical Center, Rotterdam, the Netherlands

Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands

Correspondence to: Dr. M. Kamran Ikram, Erasmus MC University Medical Center, P.O. Box 2040, 3000 CA Rotterdam, the Netherlands E-mail:

Department of Epidemiology, Erasmus MC University Medical Center, Rotterdam, the Netherlands

Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands

Francesco U.S. Mattace Raso PhD

Department of Geriatric Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands

Department of Epidemiology, Erasmus MC University Medical Center, Rotterdam, the Netherlands

Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands

Correspondence to: Dr. M. Kamran Ikram, Erasmus MC University Medical Center, P.O. Box 2040, 3000 CA Rotterdam, the Netherlands E-mail:

Lisanne J. Dommershuijsen and Alis Heshmatollah contributed equally to this article.

Relevant conflicts of interests/financial disclosures:: Nothing to report.

Orthostatic Hypotension In Patients With Parkinsons Disease And Atypical Parkinsonism

This article outlines a study which reviewed current evidences on epidemiology, diagnosis, treatment, and prognosis of orthostatic hypotension in patients with idiopathic Parkinsons disease and atypical parkinsonism. Conclusions include recommendation for further study of OH and routine screening for timely diagnosis and further assessments beyond the recommended 3 minute postural challenge currently used.

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Functional Psychosocial And Healthcare Resource Use Impacts

Falls and their consequences are of high clinical concern inpatients with PD. Falls increase the risk of injuries and increase healthcareresource use . In patients with PD, symptoms of nOHare associated with increased risk of falls and impairment of activities ofdaily living . An increased rate of falls has been demonstrated even inpatients with asymptomatic nOH when compared with patients with PD without nOH . The greater risk of falls in patientswith nOH results in more emergency department visits, hospitalizations, and useof outpatient services . In a retrospective cohortstudy, unadjusted medically attended fall-related costs were significantlyhigher for patients with PD and nOH than for patients with PD alone . Similarly, another retrospective study found thatoverall healthcare costs were more than 250% higher in patients with PD and nOHthan in those with PD alone ,even after adjusting for confounding factors .

First Step: Make The Right Diagnosis

Neurogenic Orthostatic Hypotension As Discussed By a Parkinson’s Advocate

Given its unspecific, and sometimes asymptomatic, presentation, OH should be actively screened at bedside by measuring the BP and heart rate supine and after 3 minutes upon standing . OH is diagnosed in case of a systolic BP fall 20mmHg and/or diastolic 10mmHg with respect to baseline . Standing systolic BP values < 90mmHg are also highly suggestive of OH and often predict symptoms of orthostatic intolerance . In case of milder BP falls at the 3rd minute upon standing, it is recommendable to prolong the orthostatic challenge to 510 minutes, in order to screen for delayed OH, a possible precursor of classic OH .

Once a diagnosis of OH is established, non-neurogenic causes and exacerbating factors, such as dehydration, anemia or infections should be ruled out. The medication schedule should be also reviewed for drugs with BP lowering effect, which may have been recently introduced or increased in dose: not only anti-hypertensive agents, but also dopaminergic drugs, tricyclics, opioids, neuroleptics or -blockers.

Fig.1

Management of orthostatic hypotension and supine hypertension in Parkinsons disease. OH, orthostatic hypotension BP, blood pressure HR, heart rate NSAIDs, non-steroidal anti-inflammatory drugs SNRI, serotonin-noradrenaline reuptake inhibitors. Adapted from Fanciulli et al. 2014 and Fanciulli et al., 2016 with permission from Springer and John Wiley and Sons.

Fig.2

Template of a home blood pressure diary for patients with orthostatic hypotension.

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Improvement In Severe Orthostatic Hypotension Following Carbidopa Dose Reduction

Published online by Cambridge University Press: 21 December 2017

Pharmacist Department of Pharmacy Surrey Memorial Hospital Fraser Health Authority Surrey, BC, Canada
John L. Diggle
Affiliation:Neurologist and Regional Medical Director and Head Regional Department of Medicine Fraser Health Authority Surrey, BC, CanadaClinical Assitant Professor Faculty of Medicine University of British Columbia Vancouver, BC, Canada
Penny P. Bring
Affiliation:Clinical Pharmacy Specialist Neurology Department of Pharmacy Surrey Memorial Hospital Fraser Health Authority Surrey, BC, CanadaClinical Instructor Faculty of Pharmaceutical Sciences University of British Columbia Vancouver, BC, Canada
*
Correspondence to: A.C.W. Lau, BSc , Pharmacist, Surrey Memorial Hospital Pharmacy Department, Fraser Health Authority, 13750 96 Avenue, Surrey, BC, Canada V3V 1Z2. Email:

Full Financial Disclosures For The Last 12 Months

Alessandra Fanciulli: Dr. Fanciulli reports royalties from Springer Nature Publishing Group, speaker fees and honoraria from the Austrian Autonomic Society, Austrian Parkinson Society, Ordensklinikum Linz, International Parkinson Disease and Movement Disorders Society and Theravance Biopharma and research grants from the Stichting ParkinsonFond and the Österreichischer Austausch Dienst, outside of the submitted work.

Fabian Leys: Dr. Leys reports no disclosures.

Cristian Falup-Pecurariu: Dr. Falup-Pecurariu reports royalties from Springer Nature Publishing Group, speaker fees and honoraria from the International Parkinson and Movement Disorders Society, outside of the submitted work.

Roland Thijs: Dr. Thijs reports speaker fees from Novartis, consultancy fees from Theravance Biopharma and research support from the Dutch Epilepsy Foundation Dutch, the Netherlands Organization for Health Research and Development and De Christelijke Vereniging voor de Verpleging van Lijders aan Epilepsie, outside of the submitted work.

Gregor K. Wenning: Dr. Wenning reports consultancy fees from Biogen, Biohaven, Lundbeck, Minoryx, Takeda, Theravance and research support from the Austrian Science Fund, International Parkinson Disease and Movement Disorders Society and the Medical University Innsbruck, outside of the submitted work.

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Effects Of Parkinsons Disease On Blood Pressure

This short web page explains the physical operation of blood pressure in the body, symptoms of low blood pressure and when they are most likely to occur, why low blood pressure is dangerous, medical treatments and lifestyle strategies to cope with low blood pressure, and a reminder that low blood pressure can affect the ability to drive safely.

Low Blood Pressure In Parkinson’s Disease

(PDF) Droxidopa in Patients with Neurogenic Orthostatic Hypotension ...

This 2-page article discusses the frequency of orthostatic hypotension in those with PD, the cause, symptoms and several simple measures that can be used to restore normal blood pressure regulation, including medication evaluation, increase of fluids and salty foods, caffeine, frequent small meals, environment, clothing, slow position change, bed position and medication options.

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Continuous Dopaminergic Stimulation Therapies

Deep brain stimulation

Cross-sectional studies have suggested a positive effect of subthalamic Deep Brain Stimulation on autonomous responses of PD subjects . In one of this analysis, including 14 patients, there was a mean general decrease on blood pressure in on and off stimulation status ,1), but the baroreflex responses were preserved only when the stimulation was on, suggesting, therefore, a positive influence of the DBS in BP mediated by its influence on central autonomous nervous system pathways . In another study comparing subthalamic DBS with a pharmacotherapy-only group, no positive correlation was found between the on-stimulation state and the decrease in blood pressure but this occurred in the only medicated group. Based on this finding it was suggested that subthalamic DBS did not affect cardiovascular autonomous responses . Noteworthy, in a previous longitudinal study, the initial differences of blood pressure were not found after 1years follow-up, with a similar mean blood-pressure decrease for the subthalamic DBS and the only medicated groups . Additionally, two other studies could not find differences in the cardiovascular responses of the treated subjects .

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Managed Care Approach To The Treatment Of Neurogenic Orthostatic Hypotension

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Abstract

Neurogenic orthostatic hypotension is an orphan disease that primarily affects patients with neurodegenerative disorders such as Parkinsons disease and multiple system atrophy. The first step in the management of NOH is to discontinue or minimize the use of drugs that lower blood pressure. Nonpharmacologic therapy for NOH includes physical countermaneuvers, compression abdominal binders and lower extremity stockings, recognition and avoidance of orthostatic stressors, hydration, and salt supplementation. The manage-ment of NOH should also include interventions to prevent falls. Pharmacotherapy for NOH includes the mineralocorticoid drug fludrocortisone to expand plasma volume and the sympathomimetic drugs midodrine and droxidopa. Clinical efficacy, tolerability, and the role of each drug in the treat-ment paradigm are reviewed here.

Am J Manag Care. 2015 21:S258-S268

SUMMARY

As a rare disease, NOH has unique management challenges with few well-established treatments, and it requires a patient-oriented approach in which nonphar-macologic strategies may be augmented by pharmaco-therapy. In addition, patients with NOH might be treated with drugs for comorbid disorders that exacerbate NOH and, as a result, they are at risk for drug interactions and adverse effects.5-7

Treatment Goals and Plans

Druginduced Orthostatic Hypotension

Physical Countermaneuvers and Patient Education

Fall Prevention

Pharmacotherapy of NOH

Droxidopa

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Managing Orthostatic Hypotension In Parkinsons Disease

Sometimes, orthostatic hypotension can be avoided with lifestyle approaches, including:

  • Drinking lots of water and other fluids to stay hydrated, especially during warm weather months
  • Avoiding abrupt changes in position
  • Shifting slowly from lying to sitting and then standing
  • Avoiding prolonged standing
  • Limiting or reducing alcohol intake
  • Increasing salt intake
  • Eating small, frequent meals
  • Avoiding hot drinks and hot foods1

Things that may worsen orthostatic hypotension, include:

  • Fevers
  • Straining when going to the bathroom
  • Vigorous exercise
  • Meals high in carbohydrates1

People with PD who have orthostatic hypotension may need changes in their medications, if their doctor determines their medications may be contributing to their symptoms. Physicians, specifically movement disorders specialists, are trained to know the best treatments for hypotension for PD patients and whether treatments for PD symptoms are causing hypotension. Other medications that may help manage orthostatic hypotension include Northera , ProAmatine® , Forinef® or Mestinon® . One potential side effect of these medications that raise low blood pressure when a person is standing is that they may cause high blood pressure when the person is lying down.1

The Management Of Orthostatic Hypotension In Parkinsons Disease

Management of Postural Hypotension in Parkinson’s | Parkinson’s Academy webinar

1Department of Neurology, University Hospital 12 de Octubre,, Madrid, Spain

2Department of Medicine, Faculty of Medicine, Complutense University, Madrid, Spain

3Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas, Madrid, Spain

4Instituto de Salud Carlos III, Madrid, Spain

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Orthostatic Hypotension And Neurogenic Orthostatic Hypotension

The symptoms of nOH/OH result from inadequate perfusion of targetorgans upon standing and are similar regardless of the underlying etiology. The most frequent symptoms of thecondition include postural lightheadedness or dizziness, presyncope, and falls . Lesscommon symptoms include visual disturbances, fatigue, generalized weakness,cognitive dysfunction, neck pain or discomfort , andorthostatic dyspnea .

The prevalence of nOH in patients with PD reported in studies thatdefined nOH by BP reduction criteria ranges widely in individual studies from 10to 65% ), and ameta-analysis of 25 studies identified an estimated point prevalence of 30%. Similarly, the prevalenceestimates of symptomatic nOH in patients with PD are diverse, with reportedrates ranging from 16 to 89% in individual studies . However,not all patients who have an orthostatic BP drop meeting the criteria for nOHwill report orthostatic symptoms. Results from studies in PD populations havesuggested that a substantial portion of patients meet the BP criteria for OH butare asymptomaticthat is, they report no symptoms typical of cerebralhypoperfusion .

Monitor Your Blood Pressure

You may find it useful to keep a diary of what triggers your symptoms and what makes them better or worse. This will help manage the problem.

If you have low blood pressure, you may need to tell the relevant driving authority, depending on what you drive.

At the time of printing, the government website states that you need to tell the DVLA in England Scotland and Wales or the DVA in Northern Ireland, if treatment for blood pressure causes side effects that could affect your ability to drive.

Please check with your relevant authority if you have problems with your blood pressure, as the rules may have recently changed.

Remember that you must contact your relevant driving licensing agency when you are diagnosed with Parkinsons.

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Symptoms Of Orthostatic Hypotension

Symptoms of orthostatic hypotension include lightheadedness, weakness, dizziness, difficulty thinking, feeling faint, and headache. Orthostatic hypotension is generally evaluated by measuring the blood pressure of a patient while sitting, or lying down, and again while standing. Currently, a person whose blood pressure drops more than 20 mm Hg in systolic pressure or more than 10 mm Hg in diastolic pressure is considered to have orthostatic hypotension. A new research study suggests a more accurate way to diagnose orthostatic hypotension is using a calculation called upright mean arterial blood pressure, which takes into account both the systolic and diastolic blood pressures. When this number is under 75 mm Hg, it indicates orthostatic hypotension.1

How Is Orthostatic Hypotension Treated

(PDF) Nonpharmacological treatment, fludrocortisone, and domperidone ...

Droxidopa . fludrocortisone , or midodrine capsules are approved for the treatment of orthostatic hypotension. Common side effects include headache, dizziness, nausea, high blood pressure, and fatigue.

Another approach in treating orthostatic hypotension is to decrease the pooling of blood in the legs with the use of special stockings called compression stockings. These tight stockings “compress” the veins in the legs, helping to reduce swelling and increase blood flow. There are a number of companies that make these stockings in a wide variety of sizes, and they usually can be found at stores that sell medical supplies, as well as at some pharmacies.

You should wear these stockings when you are up and about. You do not need to wear them when you are in bed. Further, it is recommended that you put the stockings on first thing in the morning while in bed and before getting up for your daily activities. It is important that you do not let the stockings bunch, gather, or roll, since this can compress the veins too much and could harm circulation. You should always watch for signs of decreased circulation, which could include discoloration of the skin, as well as pain or cramping, and numbness of the lower legs and feet.

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The Effect Of The Anti

One of the initial steps required when assessing a patient who is going to receive any anti-parkinsonian medication/treatment or who needs a dose adjustment is to anticipate the potential effect on his blood pressure, as it is one of the commonly related factors to the appearance of OH .

Several actions could help to improve the detection of this complication, either by the physician or the subject. It seems reasonable to instruct the patient about OH symptoms , although many cases go unnoticed . An initial pressor response assessment could be valuable to have a simple measurement to monitor future changes, as this measurement is one of the easiest ways to appraise OH in various healthcare settings.

Many caveats should be considered prior to establishing the real influence of PD medications on OH. First, there are different diagnostic criteria for defining OH. Additionally, much evidence is based on cross-sectional analyses and other confounding effects, as disease duration or previous autonomous nervous system damage , have not always been considered.

We present the current evidence to estimate the potential role of current PD treatments on OH. The influence of other drugs, such as antidepressants, diuretics, and antihypertensives, is not reviewed here. Nevertheless, they should be considered when dealing with this complication and decreasing the dose or stopping the responsible medication might be advisable.

Diagnosis Of Neurogenic Orthostatic Hypotension

Once a BP drop indicating OH is identified, further investigationinto the underlying cause is warranted. Patients with nOH can often bedistinguished clinically from patients with non-neurogenic OH by a bluntedorthostatic heart rate response ,although this single variable is not a perfectly sensitive or specific marker. OH accompanied by aminimal increase in heart rate from the supine- and/or seated-to-standingposition may be suggestive of nOH, whereas compensatory heart rateincreases of 15 bpm are usually observed when OH is due to non-neurogeniccauses . The results of a recentstudy suggest that a heart rate increase of < 17 bpm has better sensitivityand specificity for detecting nOH however, the rate of the orthostatic changein heart rate with falling systolic BP may be an even better indicator of nOH than the absolutechange in heart rate alone . As part of the diagnosticevaluation for nOH, exclusion of potentially confounding factors, such asdehydration, acute bleeding, and non-neurogenic causes, is necessary. An electrocardiogram,cardiac history, and medication review should be performed to rule outcardiogenic causes that may affect posturalheart rate .

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