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Review
. 2020;10(s1):S57-S64.
doi: 10.3233/JPD-202036.

Management of Orthostatic Hypotension in Parkinson's Disease

Alessandra Fanciulli  1 , Fabian Leys  1 , Cristian Falup-Pecurariu  2 , Roland Thijs  3   4 , Gregor K Wenning  1
Affiliations
Review

Management of Orthostatic Hypotension in Parkinson's Disease

Alessandra Fanciulli et al. J Parkinsons Dis. 2020.

Abstract

Orthostatic hypotension (OH) is a common non-motor feature of Parkinson's disease that may cause unexplained falls, syncope, lightheadedness, cognitive impairment, dyspnea, fatigue, blurred vision, shoulder, neck, or low-back pain upon standing. Blood pressure (BP) measurements supine and after 3 minutes upon standing screen for OH at bedside. The medical history and cardiovascular autonomic function tests ultimately distinguish neurogenic OH, which is due to impaired sympathetic nerve activity, from non-neurogenic causes of OH, such as hypovolemia and BP lowering drugs. The correction of non-neurogenic causes and exacerbating factors, lifestyle changes and non-pharmacological measures are the cornerstone of OH treatment. If these measures fail, pharmacological interventions (sympathomimetic agents and/or fludrocortisone) should be introduced stepwise depending on the severity of symptoms. About 50% of patients with neurogenic OH also suffer from supine and nocturnal hypertension, which should be monitored for with in-office, home and 24 h-ambulatory BP measurements. Behavioral measures help prevent supine hypertension, which is eventually treated with non-pharmacological measures and bedtime administration of short-acting anti-hypertensive drugs in severe cases. If left untreated, OH impacts on activity of daily living and increases the risk of syncope and falls. Supine hypertension is asymptomatic, but often limits an effective treatment of OH, increases the risk of hypertensive emergencies and, combined with OH, facilitates end-organ damage. A timely management of both OH and supine hypertension ameliorates quality of life and prevents short and long-term complications in patients with Parkinson's disease.

Keywords: Parkinson’s disease; nocturnal hypertension; orthostatic hypotension; post-prandial hypotension; supine hypertension.

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Conflict of interest statement

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 (ZonMW) 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.

Figures

Fig.1
Fig.1
Management of orthostatic hypotension and supine hypertension in Parkinson’s 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 [11] and Fanciulli et al., 2016 [37] with permission from Springer and John Wiley and Sons.
Fig.2
Fig.2
Template of a home blood pressure diary for patients with orthostatic hypotension.
See this image and copyright information in PMC

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