Management of neurogenic orthostatic hypotension

In treating patients with neurogenic orthostatic hypotension (nOH), the goal is to lessen the symptom burden, rather than attempting to achieve normal blood pressure on standing.^1,7 The stepwise management of nOH involves:⁷

1. Removing aggravating factors – hypotensive drugs should be discontinued or the dose reduced, and anaemia should be investigated (anaemia can potentially worsen OH, by reducing the oxygen carrying potential of the blood).
2. Non-pharmacological treatments – there are many changes that can be encouraged before pharmacological treatments are considered. Patients should understand the effect of posture on blood pressure, and should learn the various physical countermeasures that can raise blood pressure.
3. Pharmacological treatments – if required, the pharmacological approach to treating nOH involves one or both of two strategies: expanding the intravascular volume, and increasing peripheral vascular resistance. The selection of either, or both, approaches depends on the individual needs and clinical background of the patient.

References:
1. Maule S, Papotti G, Naso D, et al. Orthostatic hypotension: evaluation and treatment. Cardiovasc Hematol Disord Drug Targets 2007; 7 (1): 63–70.

2. Claassen DO, Adler CH, Hewitt LA, Gibbons C. Characterization of the symptoms of neurogenic orthostatic hypotension and their impact from a survey of patients and caregivers. BMC Neurol 2018; 18 (1): 125.

3. Isaacson SH. Managed care approach to the treatment of neurogenic orthostatic hypotension. Am J Manag Care 2015; 21 (13 Suppl): S258–268.

4. Freeman R. Neurogenic orthostatic hypotension. N Engl J Med 2008; 358 (6): 615–624.

5. Fanciulli A, Leys F, Falup-Pecurariu C, et al. Management of orthostatic hypotension in Parkinson’s disease. J Parkinsons Dis 2020; 10 (s1): S57–S64.

6. Kaufmann H, Norcliffe-Kaufmann L, Palma JA. Droxidopa in neurogenic orthostatic hypotension. Expert Rev Cardiovasc Ther 2015; 13 (8): 875–891.

7. Palma JA, Kaufmann H. Epidemiology, diagnosis, and management of neurogenic orthostatic hypotension. Mov Disord Clin Pract 2017; 4 (3): 298–308.