Nonpharmacological treatment, fludrocortisone, and domperidone for orthostatic hypotension in Parkinson's disease

Abstract

There is limited evidence for the treatment of orthostatic hypotension in idiopathic Parkinson's disease. The objective of this study was to determine the efficacy of three treatments (nonpharmacological therapy, fludrocortisone, and domperidone). Phase I assessed the compliance, safety, and efficacy of nonpharmacological measures. Phase II was a double-blind randomized controlled crossover trial of the two medications. Primary outcome measures consisted of the orthostatic domain of the Composite Autonomic Symptom Scale (COMPASS-OD), a clinical global impression of change (CGI), and postural blood pressure testing via bedside sphygmomanometry (Phase I) or tilt table testing (Phase II). For the 17 patients studied, nonpharmacological therapy did not significantly alter any outcome measure. Both medications improved the CGI and COMPASS-OD scores. There was a trend towards reduced blood pressure drop on tilt table testing, with domperidone having a greater effect.

Lower vascular tone and larger plasma volume in Parkinson's disease with orthostatic hypotension

“…Despite several published recommendations on the treatment of OH in PD, they are scarcely evidenced based (38). Several nonpharmacological interventions have presumed efficacy by increasing venous return or plasma volume, i.e., elastic stockings, physical counter maneuvers, salt and fluid intake, sleeping in the head-up position, or increase physical activity (38).…”

“…Several nonpharmacological interventions have presumed efficacy by increasing venous return or plasma volume, i.e., elastic stockings, physical counter maneuvers, salt and fluid intake, sleeping in the head-up position, or increase physical activity (38). Fludrocortisone (9␣-fluorohydrocortisone) and midodrine (␣-adrenoceptor agonist) are most commonly used in the pharmacological management of OH in PD (38).…”

“…Several nonpharmacological interventions have presumed efficacy by increasing venous return or plasma volume, i.e., elastic stockings, physical counter maneuvers, salt and fluid intake, sleeping in the head-up position, or increase physical activity (38). Fludrocortisone (9␣-fluorohydrocortisone) and midodrine (␣-adrenoceptor agonist) are most commonly used in the pharmacological management of OH in PD (38). The results of the present study, i.e., a lower leg vascular resistance with low norepinephrine levels and a larger plasma volume in PD ϩ OH, support the use of midodrine as a vasoconstrictive agent and, at the same time, question the use of fludrocortisone as a volume-expanding agent.…”

“…In addition, a relation is present between baroreflex-mediated vascular control (26), time to presyncope (10), and blood pressure during orthostatic challenges in autonomic failure (46). In addition, plasma volume expansion is considered an effective therapy in PD patients with OH (38). However, data on possible baseline differences in plasma volume in PD are lacking.…”

Trastornos autonómicos en enfermedad de Parkinson

“…Debemos considerar que hasta un tercio de los pacientes pueden no referir síntomas aun con caídas de presión ortostática presincopales (< 80/50 mmHg) y que en el grupo de pacientes > 70 años el 30% no recuerda una caída en los últimos 3 meses, aún habiendo sido presenciada por un familiar 16,17 . Asimismo, debemos dar importancia incluso a síntomas en apariencia vagos (desconcentración, sensación de cabeza abombada, visión borrosa, etc) que se asocian a períodos a veces prolongados de posición de pie (más de 15 minutos en algunos casos) 17,20 . La hipotensión ortostática se defi ne con una caída sostenida de PA > 20 mmHg sistólica o más de 10 mmHg la diastólica, tras al menos 3 minutos de ponerse de pie 18 .…”