101
|
Palma JA, Kaufmann H. Treatment of autonomic dysfunction in Parkinson disease and other synucleinopathies. Mov Disord 2018; 33:372-390. [PMID: 29508455 PMCID: PMC5844369 DOI: 10.1002/mds.27344] [Citation(s) in RCA: 130] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 01/11/2018] [Accepted: 01/24/2018] [Indexed: 12/12/2022] Open
Abstract
Dysfunction of the autonomic nervous system afflicts most patients with Parkinson disease and other synucleinopathies such as dementia with Lewy bodies, multiple system atrophy, and pure autonomic failure, reducing quality of life and increasing mortality. For example, gastrointestinal dysfunction can lead to impaired drug pharmacodynamics causing a worsening in motor symptoms, and neurogenic orthostatic hypotension can cause syncope, falls, and fractures. When recognized, autonomic problems can be treated, sometimes successfully. Discontinuation of potentially causative/aggravating drugs, patient education, and nonpharmacological approaches are useful and should be tried first. Pathophysiology-based pharmacological treatments that have shown efficacy in controlled trials of patients with synucleinopathies have been approved in many countries and are key to an effective management. Here, we review the treatment of autonomic dysfunction in patients with Parkinson disease and other synucleinopathies, summarize the nonpharmacological and current pharmacological therapeutic strategies including recently approved drugs, and provide practical advice and management algorithms for clinicians, with focus on neurogenic orthostatic hypotension, supine hypertension, dysphagia, sialorrhea, gastroparesis, constipation, neurogenic overactive bladder, underactive bladder, and sexual dysfunction. © 2018 International Parkinson and Movement Disorder Society.
Collapse
Affiliation(s)
- Jose-Alberto Palma
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, New York, New York, USA
| | - Horacio Kaufmann
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, New York, New York, USA
| |
Collapse
|
102
|
Merola A, Sawyer RP, Artusi CA, Suri R, Berndt Z, Lopez-Castellanos JR, Vaughan J, Vizcarra JA, Romagnolo A, Espay AJ. Orthostatic hypotension in Parkinson disease: Impact on health care utilization. Parkinsonism Relat Disord 2018; 47:45-49. [DOI: 10.1016/j.parkreldis.2017.11.344] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Revised: 10/24/2017] [Accepted: 11/27/2017] [Indexed: 12/18/2022]
|
103
|
Klanbut S, Phattanarudee S, Wongwiwatthananukit S, Suthisisang C, Bhidayasiri R. Symptomatic orthostatic hypotension in Parkinson's disease patients: Prevalence, associated factors and its impact on balance confidence. J Neurol Sci 2017; 385:168-174. [PMID: 29406900 DOI: 10.1016/j.jns.2017.12.037] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Revised: 12/26/2017] [Accepted: 12/28/2017] [Indexed: 01/17/2023]
Abstract
BACKGROUND Orthostatic hypotension (OH) is a commonly reported sign of the cardiovascular autonomic dysfunctions associated with Parkinson's disease (PD). Patients might suffer from a variety of the clinical symptoms of OH, including dizziness, lightheadedness, or problems with vision and fatigue. OBJECTIVES To determine the prevalence of, and factors associated with, symptomatic orthostatic hypotension (OH) in Parkinson's disease (PD) and to identify any relationships between the clinical symptoms of OH and balance confidence in this patient population. METHODS Symptomatic OH was defined as a systolic or diastolic BP fall of ≥20 or ≥10mmHg respectively, within 3min of standing and an Orthostatic Hypotension Questionnaire (OHQ) score of more than zero. Factors related to symptomatic OH were identified from a multivariate logistic regression analysis. Pearson's correlation test was used to reveal any relationships between the clinical symptoms of OH and a patient's confidence in their ability to balance, assessed using the Activities-specific Balance Confidence (ABC) scale. RESULTS 100 Thai PD patients were consecutively recruited into this study. The prevalence of symptomatic OH was 18%, asymptomatic OH was 4%, while 78% were patients without OH. Factors associated with symptomatic OH were age (OR, 95%CI: 1.06, 1.003-1.115, p=0.038) and hypertension (OR, 95%CI: 6.16, 1.171-32.440, p=0.032). A significant and negative correlation (r=-0.229, p=0.022) between OHQ composite scores and item 3 of the ABC scale (picking up slippers from floor), one of the movements in a vertical orientation, was found. CONCLUSION Elderly PD patients and with a co-morbidity of essential hypertension should be closely evaluated for the presence of symptomatic OH. In addition, they should be advised to change positions slowly, especially those in a vertical orientation.
Collapse
Affiliation(s)
- Siranan Klanbut
- Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Chulalongkorn University, Bangkok, Thailand
| | - Siripan Phattanarudee
- Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Chulalongkorn University, Bangkok, Thailand.
| | | | | | - Roongroj Bhidayasiri
- Chulalongkorn Center of Excellence for Parkinson's Disease and Related Disorders, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| |
Collapse
|
104
|
Merola A, Romagnolo A, Rosso M, Suri R, Berndt Z, Maule S, Lopiano L, Espay AJ. Autonomic dysfunction in Parkinson's disease: A prospective cohort study. Mov Disord 2017; 33:391-397. [DOI: 10.1002/mds.27268] [Citation(s) in RCA: 84] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Revised: 11/09/2017] [Accepted: 11/19/2017] [Indexed: 11/10/2022] Open
Affiliation(s)
- Aristide Merola
- Gardner Family Center for Parkinson's Disease and Movement Disorders, Department of Neurology; University of Cincinnati; Cincinnati Ohio USA
| | - Alberto Romagnolo
- Department of Neuroscience “Rita Levi Montalcini”; University of Turin; Torino Italy
| | - Michela Rosso
- Gardner Family Center for Parkinson's Disease and Movement Disorders, Department of Neurology; University of Cincinnati; Cincinnati Ohio USA
| | - Ritika Suri
- Gardner Family Center for Parkinson's Disease and Movement Disorders, Department of Neurology; University of Cincinnati; Cincinnati Ohio USA
| | - Zoe Berndt
- Gardner Family Center for Parkinson's Disease and Movement Disorders, Department of Neurology; University of Cincinnati; Cincinnati Ohio USA
| | - Simona Maule
- Department of Medical Sciences, Autonomic Unit and Hypertension Unit; University of Turin; Torino Italy
| | - Leonardo Lopiano
- Department of Neuroscience “Rita Levi Montalcini”; University of Turin; Torino Italy
| | - Alberto J. Espay
- Gardner Family Center for Parkinson's Disease and Movement Disorders, Department of Neurology; University of Cincinnati; Cincinnati Ohio USA
| |
Collapse
|
105
|
Abstract
Cardiovascular autonomic dysfunctions, including neurogenic orthostatic hypotension, supine hypertension and post-prandial hypotension, are relatively common in patients with Parkinson disease. Recent evidence suggests that early autonomic impairment such as cardiac autonomic denervation and even neurogenic orthostatic hypotension occur prior to the appearance of the typical motor deficits associated with the disease. When neurogenic orthostatic hypotension develops, patients with Parkinson disease have an increased risk of mortality, falls, and trauma-related to falls. Neurogenic orthostatic hypotension reduces quality of life and contributes to cognitive decline and physical deconditioning. The co-existence of supine hypertension complicates the treatment of neurogenic orthostatic hypotension because it involves the use of drugs with opposing effects. Furthermore, treatment of neurogenic orthostatic hypotension is challenging because of few therapeutic options; in the past 20 years, the US Food and Drug Administration approved only two drugs for the treatment of this condition. Small, open-label or randomized studies using acute doses of different pharmacologic probes suggest benefit of other drugs as well, which could be used in individual patients under close monitoring. This review describes the pathophysiology of neurogenic orthostatic hypotension and supine hypertension in Parkinson disease. We discuss the mode of action and therapeutic efficacy of different pharmacologic agents used in the treatment of patients with cardiovascular autonomic failure.
Collapse
Affiliation(s)
- Cyndya A. Shibao
- Department of Medicine, Division of Clinical Pharmacology, Vanderbilt Autonomic Dysfunction Center, Vanderbilt University Medical Center, Nashville, TN
| | - Horacio Kaufmann
- Department of Neurology, NYU Langone Medical Center, Dysautonomia Center, 530 1st Avenue, New York, NY, USA.
| |
Collapse
|
106
|
Bacchi S, Chim I, Kramer P, Postuma RB. Domperidone for Hypotension in Parkinson’s Disease: A Systematic Review. JOURNAL OF PARKINSONS DISEASE 2017; 7:603-617. [DOI: 10.3233/jpd-171209] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
| | - Ivana Chim
- University of Adelaide, Adelaide, SA, Australia
| | | | | |
Collapse
|
107
|
Abstract
Neurogenic orthostatic hypotension (NOH) can be present in a number of disorders, including synucleinopathies, autoimmune disorders, and various genetic disorders. All are characterized by defective norepinephrine release from sympathetic terminals upon standing, resulting in impaired vasoconstriction. NOH is defined as a drop in systolic blood pressure ≥20 mmHg or diastolic blood pressure ≥10 mmHg, or both, within 3 minutes of standing or head up-tilt at a minimum of 60°. However, approximately 50% of patients have associated supine hypertension, which greatly complicates treatment. Supine hypertension not only is a common side effect of many anti-hypotensive agents but is also present in untreated patients, suggesting it is, in part, innate to the pathophysiology of autonomic dysfunction. Pathological mechanisms differ depending on the underlying autonomic disorder. In central neurodegenerative disorders, residual post-ganglionic sympathetic activity is likely the primary mechanism, whereas plasma angiotensin, aldosterone, and inappropriate mineralocorticoid receptor activity may contribute in peripheral autonomic lesions. Baroreflex failure/loss of baroreflex buffering is common to both. More work is required. Clinically, there is much dispute regarding the treatment of supine hypertension when there is a risk of exacerbating orthostatic hypotension. However, given the similar levels of end-organ damage (i.e., heart attack and stroke) seen with transient hypertension, it seems clear that treatment is important. Current therapies for both NOH and supine hypertension include a combination of pharmacological and conservative measures. However, in addition to the current standard of care, protocols may consider 24-h blood pressure monitoring and potential future examination of the peripheral post-ganglionic sympathetic nerves in order to apply individualized adjunct therapies. Finally, no anti-hypertensive agents are currently approved for use in this patient population, and development of novel therapies should focus on short-acting agents, selective to the supine position, that act primarily at night when hypertension is most severe/prolonged.
Collapse
Affiliation(s)
- Jacquie Baker
- School of Kinesiology, Western University, London, ON, Canada.,Department of Clinical Neurological Sciences, Rm. C7-131, University Hospital, London Health Sciences Centre, 339 Windermere Road, London, ON, N6A 5A5, Canada
| | - Kurt Kimpinski
- School of Kinesiology, Western University, London, ON, Canada. .,Department of Clinical Neurological Sciences, Rm. C7-131, University Hospital, London Health Sciences Centre, 339 Windermere Road, London, ON, N6A 5A5, Canada. .,Schulich School of Medicine and Dentistry, Western University, London, ON, Canada.
| |
Collapse
|
108
|
Morbus Parkinson im Alter. Z Gerontol Geriatr 2017; 50:547-559. [DOI: 10.1007/s00391-017-1284-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Revised: 06/01/2017] [Accepted: 06/20/2017] [Indexed: 12/15/2022]
|
109
|
Fuente Mora C, Palma JA, Kaufmann H, Norcliffe-Kaufmann L. Cerebral autoregulation and symptoms of orthostatic hypotension in familial dysautonomia. J Cereb Blood Flow Metab 2017; 37:2414-2422. [PMID: 27613312 PMCID: PMC5531340 DOI: 10.1177/0271678x16667524] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Familial dysautonomia is an inherited autonomic disorder with afferent baroreflex failure. We questioned why despite low blood pressure standing, surprisingly few familial dysautonomia patients complain of symptomatic hypotension or have syncope. Using transcranial Doppler ultrasonography of the middle cerebral artery, we measured flow velocity (mean, peak systolic, and diastolic), area under the curve, pulsatility index, and height of the dictrotic notch in 25 patients with familial dysautonomia and 15 controls. In patients, changing from sitting to a standing position, decreased BP from 124 ± 4/64 ± 3 to 82 ± 3/37 ± 2 mmHg (p < 0.0001, for both). Despite low BP, all patients denied orthostatic symptoms. Middle cerebral artery velocity fell minimally, and the magnitude of the reductions were similar to those observed in healthy controls, in whom BP upright did not fall. While standing, patients had a greater fall in cerebrovascular resistance (p < 0.0001), an increase in pulsatility (p < 0.0001), and a deepening of the dicrotic notch (p = 0.0010), findings all consistent with low cerebrovascular resistance. No significant changes occurred in controls. Patients born with baroreflex deafferentation retain the ability to buffer wide fluctuations in BP and auto-regulate cerebral blood flow. This explains how they can tolerate extremely low BPs standing that would otherwise induce syncope.
Collapse
Affiliation(s)
| | | | | | - Lucy Norcliffe-Kaufmann
- Lucy Norcliffe-Kaufmann, Department of Neurology, Dysautonomia Center, New York University School of Medicine, 530 First Avenue, Suite 9Q, New York, NY 10016, USA.
| |
Collapse
|
110
|
Neurogenic orthostatic hypotension: the very basics. Clin Auton Res 2017; 27:39-43. [PMID: 28620715 PMCID: PMC5524853 DOI: 10.1007/s10286-017-0437-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Accepted: 06/08/2017] [Indexed: 12/03/2022]
|
111
|
Espay AJ, LeWitt PA, Hauser RA, Merola A, Masellis M, Lang AE. Neurogenic orthostatic hypotension and supine hypertension in Parkinson's disease and related synucleinopathies: prioritisation of treatment targets. Lancet Neurol 2017; 15:954-966. [PMID: 27478953 DOI: 10.1016/s1474-4422(16)30079-5] [Citation(s) in RCA: 87] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Revised: 03/21/2016] [Accepted: 05/12/2016] [Indexed: 12/18/2022]
Abstract
Neurogenic orthostatic hypotension and supine hypertension are common manifestations of cardiovascular dysautonomia in Parkinson's disease and related synucleinopathies. Because these disorders are haemodynamic opposites, improvement in one might be achieved at the expense of worsening of the other. Thus, management decisions necessitate assessment of the individual risks for patients with coexistent neurogenic orthostatic hypotension and supine hypertension. Whereas neurogenic orthostatic hypotension poses risks for falls and can be associated with cognitive impairment in the short term, chronic supine hypertension can be associated with stroke and myocardial infarction in the long term. Because few clinical trial data exist for outcomes in patients with coexistent neurogenic orthostatic hypotension and supine hypertension, clinicians need to balance, on the basis of comorbidities and disease staging, the potential immediate benefits of treatment for neurogenic orthostatic hypotension and the long-term risks of supine hypertension treatment in each patient. Future research needs to focus on ascertaining a safe degree of supine hypertension when treating neurogenic orthostatic hypotension; the effectiveness of nocturnal antihypertensive therapy in patients with coexistent neurogenic orthostatic hypotension and supine hypertension; and the prevalence, scope, and therapeutic requirements for managing neurogenic orthostatic hypotension that manifests with falls or cognitive impairment, but without postural lightheadedness or near syncope.
Collapse
Affiliation(s)
- Alberto J Espay
- Gardner Family Center for Parkinson's Disease and Movement Disorders, Department of Neurology, University of Cincinnati, Cincinnati, OH, USA.
| | - Peter A LeWitt
- Parkinson's Disease and Movement Disorders Program, Henry Ford Hospital, West Bloomfield, MI, USA; Department of Neurology, Wayne State University School of Medicine, West Bloomfield, MI, USA
| | - Robert A Hauser
- USF Health Byrd NPF Parkinson's Disease and Movement Disorders Center of Excellence, Tampa, FL, USA
| | - Aristide Merola
- Department of Neuroscience, University of Torino, Torino, Italy
| | - Mario Masellis
- Cognitive & Movement Disorders Clinic, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Anthony E Lang
- Movement Disorders Clinic and the Edmond J Safra Program in Parkinson's Disease, University Health Network, University of Toronto, Toronto, ON, Canada
| |
Collapse
|
112
|
Pilotto A, Heinzel S, Suenkel U, Lerche S, Brockmann K, Roeben B, Schaeffer E, Wurster I, Yilmaz R, Liepelt-Scarfone I, von Thaler AK, Metzger FG, Eschweiler GW, Postuma RB, Maetzler W, Berg D. Application of the movement disorder society prodromal Parkinson's disease research criteria in 2 independent prospective cohorts. Mov Disord 2017; 32:1025-1034. [DOI: 10.1002/mds.27035] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Revised: 03/27/2017] [Accepted: 03/30/2017] [Indexed: 12/15/2022] Open
Affiliation(s)
- Andrea Pilotto
- Department of Neurodegeneration, Hertie Institute for Clinical Brain Research; University of Tuebingen; Tuebingen Germany
- Neurology Unit, Department of Clinical and Experimental Sciences; University of Brescia, Brescia, Italy and Parkinson's Disease Rehabilitation Centre, FERB ONLUS S.Isidoro Hospital, Trescore Balneario (BG); Italy
| | - Sebastian Heinzel
- Department of Neurodegeneration, Hertie Institute for Clinical Brain Research; University of Tuebingen; Tuebingen Germany
- Department of Neurology; Christian-Albrechts-University; Kiel Germany
| | - Ulrike Suenkel
- Department of Neurodegeneration, Hertie Institute for Clinical Brain Research; University of Tuebingen; Tuebingen Germany
| | - Stefanie Lerche
- Department of Neurodegeneration, Hertie Institute for Clinical Brain Research; University of Tuebingen; Tuebingen Germany
| | - Kathrin Brockmann
- Department of Neurodegeneration, Hertie Institute for Clinical Brain Research; University of Tuebingen; Tuebingen Germany
| | - Benjamin Roeben
- Department of Neurodegeneration, Hertie Institute for Clinical Brain Research; University of Tuebingen; Tuebingen Germany
| | - Eva Schaeffer
- Department of Neurology; Christian-Albrechts-University; Kiel Germany
| | - Isabel Wurster
- Department of Neurodegeneration, Hertie Institute for Clinical Brain Research; University of Tuebingen; Tuebingen Germany
| | - Rezzak Yilmaz
- Department of Neurodegeneration, Hertie Institute for Clinical Brain Research; University of Tuebingen; Tuebingen Germany
| | - Inga Liepelt-Scarfone
- Department of Neurodegeneration, Hertie Institute for Clinical Brain Research; University of Tuebingen; Tuebingen Germany
- German Center for Neurodegenerative Diseases; Tuebingen Germany
| | - Anna-Katharina von Thaler
- Department of Neurodegeneration, Hertie Institute for Clinical Brain Research; University of Tuebingen; Tuebingen Germany
| | - Florian G. Metzger
- Department of Psychiatry and Psychotherapy, Geriatric Center; Tuebingen University Hospital; Tuebingen Germany
| | - Gerhard W. Eschweiler
- Department of Psychiatry and Psychotherapy, Geriatric Center; Tuebingen University Hospital; Tuebingen Germany
| | - Ron B. Postuma
- Department of Neurology; Montreal General Hospital; Montreal Quebec Canada
| | - Walter Maetzler
- Department of Neurodegeneration, Hertie Institute for Clinical Brain Research; University of Tuebingen; Tuebingen Germany
- Department of Neurology; Christian-Albrechts-University; Kiel Germany
| | - Daniela Berg
- Department of Neurodegeneration, Hertie Institute for Clinical Brain Research; University of Tuebingen; Tuebingen Germany
- Department of Neurology; Christian-Albrechts-University; Kiel Germany
| |
Collapse
|
113
|
Biaggioni I, Arthur Hewitt L, Rowse GJ, Kaufmann H. Integrated analysis of droxidopa trials for neurogenic orthostatic hypotension. BMC Neurol 2017; 17:90. [PMID: 28494751 PMCID: PMC5427571 DOI: 10.1186/s12883-017-0867-5] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Accepted: 04/26/2017] [Indexed: 11/17/2022] Open
Abstract
Background Droxidopa, a prodrug of norepinephrine, was approved for treatment of neurogenic orthostatic hypotension (nOH) due to primary autonomic disorders based on 3 randomized double-blind studies. We performed safety and efficacy analyses of this pooled dataset (n = 460). Methods Efficacy was assessed using Orthostatic Hypotension Questionnaire (OHQ) scores (composite and individual items). Safety and tolerability were also examined. Results Droxidopa improved virtually all nOH symptom scores compared with placebo, significantly reducing OHQ composite score (−2.68 ± 2.20 vs −1.82 ± 2.34 units; P < 0.001), dizziness/lightheadedness score (−3.0 ± 2.9 vs −1.8 ± 3.1 units; P < 0.001), and 3 of 5 other symptom assessments (visual disturbances, weakness, and fatigue [P ≤ 0.010]). Droxidopa significantly improved 3 of 4 measures of activities of daily living (standing a long time, walking a short time, and walking a long time [P ≤ 0.003]) and significantly increased upright systolic blood pressure (11.5 ± 20.5 vs 4.8 ± 21.0 mmHg for placebo; P < 0.001). Droxidopa was effective in patients using inhibitors of dopa decarboxylase (DDCI; the enzyme that converts droxidopa to norepinephrine), but its efficacy was numerically greater in non-DDCI users. Droxidopa was well-tolerated. Rates of most adverse events were similar between groups. Supine hypertension rates were low, but slightly higher in patients receiving droxidopa (≤7.9% vs ≤4.6% for placebo); patients with severe hypertension at screening were excluded from these studies. Conclusions Droxidopa is effective for the treatment of nOH in patients with primary autonomic disorders and is generally well-tolerated. A longer trial is underway to confirm efficacy beyond the ≤2 to 10 - week period assessed in the current trials. Trial registration ClinicalTrials.gov identifiers: NCT00782340, first received October 29, 2008; NCT00633880, first received March 5, 2008; and NCT01176240, first received July 30, 2010.
Collapse
Affiliation(s)
- Italo Biaggioni
- Department of Medicine, Division of Clinical Pharmacology, 560A RRB, Vanderbilt University School of Medicine, Nashville, TN, 37232, USA.
| | | | - Gerald J Rowse
- Lundbeck LLC, 6 Parkway North, Deerfield, IL, 60015, USA
| | - Horacio Kaufmann
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, 530 First Avenue, Suite 9Q, New York, NY, 10016, USA
| |
Collapse
|
114
|
Palma J, Kaufmann H. Epidemiology, Diagnosis, and Management of Neurogenic Orthostatic Hypotension. Mov Disord Clin Pract 2017; 4:298-308. [PMID: 28713844 PMCID: PMC5506688 DOI: 10.1002/mdc3.12478] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Revised: 01/13/2017] [Accepted: 01/23/2017] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Orthostatic hypotension (OH) is a sustained fall in blood pressure on standing which can cause symptoms of organ hypoperfusion. OH is associated with increased morbidity and mortality and leads to a significant number of hospital admissions particularly in the elderly (233 per 100,000 patients over 75 years of age in the US). OH can be due to volume depletion, blood loss, large varicose veins, medications, or due to defective activation of sympathetic nerves and reduced norepinephrine release upon standing (i.e., neurogenic OH). METHODS AND FINDINGS Literature review. Neurogenic OH is a frequent and disabling problem in patients with synucleinopathies such as Parkinson disease, multiple system atrophy, and pure autonomic failure, and is commonly associated with supine hypertension. Several pharmacological and non-pharmacological therapeutic options are available. CONCLUSIONS Here we review the epidemiology, diagnosis, and management of neurogenic OH, and provide an algorithm for its treatment emphasizing the importance of removing aggravating factors, implementing non-pharmacologic measures, and selecting appropriate pharmacological treatments.
Collapse
Affiliation(s)
- Jose‐Alberto Palma
- Department of NeurologyDysautonomia CenterNew York University School of MedicineNew YorkNYUSA
| | - Horacio Kaufmann
- Department of NeurologyDysautonomia CenterNew York University School of MedicineNew YorkNYUSA
| |
Collapse
|
115
|
Schreglmann SR, Büchele F, Sommerauer M, Epprecht L, Kägi G, Hägele-Link S, Götze O, Zimmerli L, Waldvogel D, Baumann CR. Pyridostigmine bromide versus fludrocortisone in the treatment of orthostatic hypotension in Parkinson's disease - a randomized controlled trial. Eur J Neurol 2017; 24:545-551. [PMID: 28224720 DOI: 10.1111/ene.13260] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2016] [Accepted: 01/11/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND PURPOSE Evidence for effective treatment options for orthostatic hypotension (OH) in Parkinson's disease (PD) is scarce. Elevation of cholinergic tone with pyridostigmine bromide has been reported as a way to improve blood pressure (bp) regulation in neurogenic hypotension without causing supine hypertension. METHODS This was a double-centre, double-blind, randomized, active-control, crossover, phase II non-inferiority trial of pyridostigmine bromide for OH in PD (clinicaltrials.gov NCT01993680). Patients with confirmed OH were randomized to 14 days 3 × 60 mg/day pyridostigmine bromide or 1 × 0.2 mg/day fludrocortisone before crossover. Outcome was measured by peripheral and central bp monitoring during the Schellong manoeuvre and questionnaires. RESULTS Thirteen participants were enrolled between April 2013 and April 2015 with nine participants completing each trial arm. Repeated measures comparison showed a significant 37% improvement with fludrocortisone for the primary outcome diastolic bp drop on orthostatic challenge (baseline 22.9 ± 13.6 vs. pyridostigmine bromide 22.1 ± 17.0 vs. fludrocortisone 14.0 ± 12.6 mmHg; P = 0.04), whilst pyridostigmine bromide had no effect. Fludrocortisone caused an 11% peripheral systolic supine bp rise (baseline 128.4 ± 12.8 vs. pyridostigmine bromide 130.4 ± 18.3 vs. fludrocortisone 143.2 ± 10.1 mmHg; P = 0.01) but no central mean arterial supine bp rise (baseline 107.2 ± 7.8 vs. pyridostigmine bromide 97.0 ± 12.0 vs. fludrocortisone 107.3 ± 6.3 mmHg; P = 0.047). Subjective OH severity, motor score and quality of life remained unchanged by both study interventions. CONCLUSIONS Pyridostigmine bromide is inferior to fludrocortisone in the treatment of OH in PD. This trial provides first objective evidence of the efficacy of 0.2 mg/day fludrocortisone for OH in PD, causing minor peripheral but no central supine hypertension. In addition to peripheral bp, future trials should include central bp measurements, known to correlate more closely with cardiovascular risk.
Collapse
Affiliation(s)
- S R Schreglmann
- Department of Neurology, University Hospital Zurich, Zurich, Switzerland.,Department of Neurology, Kantonsspital St Gallen, St Gallen, Switzerland
| | - F Büchele
- Department of Neurology, University Hospital Zurich, Zurich, Switzerland
| | - M Sommerauer
- Department of Neurology, University Hospital Zurich, Zurich, Switzerland
| | - L Epprecht
- Department of Neurology, University Hospital Zurich, Zurich, Switzerland
| | - G Kägi
- Department of Neurology, Kantonsspital St Gallen, St Gallen, Switzerland
| | - S Hägele-Link
- Department of Neurology, Kantonsspital St Gallen, St Gallen, Switzerland
| | - O Götze
- Division of Gastroenterology, University Hospital Zurich, Zurich, Switzerland
| | - L Zimmerli
- Division of Internal Medicine, University Hospital Zurich, Zurich, Switzerland
| | - D Waldvogel
- Department of Neurology, University Hospital Zurich, Zurich, Switzerland
| | - C R Baumann
- Department of Neurology, University Hospital Zurich, Zurich, Switzerland
| |
Collapse
|
116
|
Hommel ALAJ, Faber MJ, Weerkamp NJ, van Dijk JG, Bloem BR, Koopmans RT. Prevalence and Prescribed Treatments of Orthostatic Hypotension in Institutionalized Patients with Parkinson’s Disease. JOURNAL OF PARKINSONS DISEASE 2016; 6:805-810. [DOI: 10.3233/jpd-160853] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- ALAJ Hommel
- Radboud University Medical Center, Donders Institute for Brain, Cognition and Behaviour, Nijmegen, The Netherlands, Groenhuysen Organisation, Roosendaal, The Netherlands
| | - MJ Faber
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen, The Netherlands
| | - NJ Weerkamp
- Department of Neurology, Bronovo Medical Center, The Hague, The Netherlands
| | - JG van Dijk
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
| | - BR Bloem
- Radboud University Medical Center, Donders Institute for Brain, Cognition and Behaviour, Department of Neurology, Nijmegen, The Netherlands
| | - RT Koopmans
- Radboud University Medical Center, Department of Primary and Community care, Centre for Family Medicine, Geriatric Care and Public health, Nijmegen, The Netherlands
- Joachim & Anna, Center for Specialized Geriatric Care, Nijmegen
| |
Collapse
|
117
|
Akbar U, Kurkchubasche AG, Friedman JH. Perioperative management of Parkinson’s disease. Expert Rev Neurother 2016; 17:301-308. [DOI: 10.1080/14737175.2017.1241143] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Umer Akbar
- Department of Neurology, Brown University, Rhode Island Hospital, Providence, RI, USA
| | - Arlet G. Kurkchubasche
- Department of Surgery and Pediatrics, Brown University, Hasbro Children’s Hospital, Providence, RI, USA
| | - Joseph H. Friedman
- Department of Neurology, Brown University, Butler Hospital, Providence, RI, USA
| |
Collapse
|
118
|
Merola A, Romagnolo A, Rosso M, Lopez-Castellanos JR, Wissel BD, Larkin S, Bernardini A, Zibetti M, Maule S, Lopiano L, Espay AJ. Orthostatic hypotension in Parkinson's disease: Does it matter if asymptomatic? Parkinsonism Relat Disord 2016; 33:65-71. [PMID: 27641792 DOI: 10.1016/j.parkreldis.2016.09.013] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2016] [Revised: 08/31/2016] [Accepted: 09/10/2016] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Orthostatic hypotension (OH) may frequently be asymptomatic in patients with Parkinson's disease (PD). However, the relationship between symptomatic/asymptomatic status and functional disability remains unclear. METHODS Using orthostatic blood pressure (BP) measurements and the Orthostatic Hypotension Symptom Assessment (OHSA) questionnaire, 121 consecutive PD patients without history of chronic hypertension and not taking alpha-adrenergic antagonists for bladder disorders were classified according to (1) OH symptomatic status, based on presence/absence of orthostatic symptoms (symptomatic OH: OHSA item 1 ≥ 1), and (2) OH severity, based on the magnitude of BP fall on the lying-to-standing test: OH- (<20/10 mmHg); moderate OH+ (≥20/10 mmHg but < 30/15 mmHg); and severe OH+ (≥30/15 mmHg). The primary endpoints were the activities of daily living/instrumental activities of daily living (ADL/iADL) and the Ambulatory Capacity Measure (ACM). Secondary endpoints included PD quality of life (PDQ-8) and prevalence of falls. RESULTS The overall prevalence of OH+ was 30.6% (37/121 patients), with 62.2% symptomatic (23/37) and 37.8% asymptomatic (14/37). Symptomatic and asymptomatic OH + patients had similar impairments in ADL/iADL and ACM, significantly worse than OH- (p ≤ 0.035). There was a trend for worse ADL/iADL and ACM scores in severe OH + compared to moderate OH+, but both were worse than OH- (p ≤ 0.048). Symptomatic and asymptomatic OH + showed similar impairment in PDQ-8 and higher prevalence of falls compared to OH-. CONCLUSIONS Asymptomatic OH+ was associated with similar impairments in ADL/iADL and ACM than symptomatic OH+. These findings support screening for OH in PD patients regardless of postural lightheadedness.
Collapse
Affiliation(s)
- Aristide Merola
- Gardner Family Center for Parkinson's Disease and Movement Disorders, Department of Neurology, University of Cincinnati, Cincinnati, OH, USA.
| | - Alberto Romagnolo
- Department of Neuroscience "Rita Levi Montalcini", University of Turin, Via Cherasco 15, 10124, Torino, Italy
| | - Michela Rosso
- Gardner Family Center for Parkinson's Disease and Movement Disorders, Department of Neurology, University of Cincinnati, Cincinnati, OH, USA
| | - José Ricardo Lopez-Castellanos
- Gardner Family Center for Parkinson's Disease and Movement Disorders, Department of Neurology, University of Cincinnati, Cincinnati, OH, USA
| | - Benjamin D Wissel
- Gardner Family Center for Parkinson's Disease and Movement Disorders, Department of Neurology, University of Cincinnati, Cincinnati, OH, USA
| | - Sydney Larkin
- Gardner Family Center for Parkinson's Disease and Movement Disorders, Department of Neurology, University of Cincinnati, Cincinnati, OH, USA
| | - Andrea Bernardini
- Department of Neuroscience "Rita Levi Montalcini", University of Turin, Via Cherasco 15, 10124, Torino, Italy
| | - Maurizio Zibetti
- Department of Neuroscience "Rita Levi Montalcini", University of Turin, Via Cherasco 15, 10124, Torino, Italy
| | - Simona Maule
- Department of Medical Sciences, Autonomic Unit and Hypertension Unit, University of Turin, Corso Bramante 88, 10126, Torino, Italy
| | - Leonardo Lopiano
- Department of Neuroscience "Rita Levi Montalcini", University of Turin, Via Cherasco 15, 10124, Torino, Italy
| | - Alberto J Espay
- Gardner Family Center for Parkinson's Disease and Movement Disorders, Department of Neurology, University of Cincinnati, Cincinnati, OH, USA
| |
Collapse
|
119
|
Velseboer DC, de Haan RJ, Post B, Krediet CTPP, Verberne HJ, de Bie RMA. Orthostatic Hypotension in Parkinson's Disease: The Relation of Blood Pressure Tests and Symptoms in Daily Life. Mov Disord Clin Pract 2016; 4:329-334. [PMID: 30363407 DOI: 10.1002/mdc3.12415] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2016] [Revised: 05/16/2016] [Accepted: 06/28/2016] [Indexed: 11/07/2022] Open
Abstract
Background Orthostatic hypotension (OH) is common in Parkinson's disease (PD), but the relation between the results of orthostatic blood pressure tests and orthostatic symptoms in daily life is not clear. Methods We performed a cross-sectional study in an incident nontertiary care cohort of PD patients with additional recruitment of PD patients from our own outpatient clinic. We recruited sex- and age-matched controls. All participants underwent orthostatic blood pressure tests using continuous blood pressure measurements. Orthostatic symptoms experienced in daily life were assessed using autonomic symptom questionnaires (SCOPA-AUT and COMPASS-31). Results A total of 83 PD patients and 35 controls were included. Mean patient age was 69.2 years (standard deviation [SD]: 10.0). Mean disease duration was 6.6 years (SD, 0.8). The estimated prevalence of OH in PD was 24.1% (95% confidence interval: 16.2-34.3). There was no significant difference between PD patients with and without OH regarding reported daily orthostatic symptoms. Alternative OH criteria did not substantially improve this. Conclusions Perceived orthostatic symptoms in daily life have no clear association with the results of a single orthostatic blood pressure test. Better diagnostic strategies are needed.
Collapse
Affiliation(s)
- Daan C Velseboer
- Department of Neurology Academic Medical Center Amsterdam The Netherlands
| | - Rob J de Haan
- Clinical Research Unit Academic Medical Center Amsterdam The Netherlands
| | - Bart Post
- Department of Neurology Radboud University Medical Center Nijmegen The Netherlands
| | - C T P Paul Krediet
- Department of Internal Medicine Academic Medical Center Amsterdam The Netherlands
| | - Hein J Verberne
- Department of Nuclear Medicine Academic Medical Center Amsterdam The Netherlands
| | - Rob M A de Bie
- Department of Neurology Academic Medical Center Amsterdam The Netherlands
| |
Collapse
|
120
|
Kaufmann H, Norcliffe-Kaufmann L, Hewitt LA, Rowse GJ, White WB. Effects of the novel norepinephrine prodrug, droxidopa, on ambulatory blood pressure in patients with neurogenic orthostatic hypotension. ACTA ACUST UNITED AC 2016; 10:819-826. [PMID: 27622314 DOI: 10.1016/j.jash.2016.07.009] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Revised: 07/15/2016] [Accepted: 07/18/2016] [Indexed: 12/26/2022]
Abstract
The prodrug droxidopa increases blood pressure (BP) in patients with neurogenic orthostatic hypotension. The BP profile of droxidopa in neurogenic orthostatic hypotension patients (n = 18) was investigated using ambulatory BP monitoring. Following dose optimization and a washout period, 24-hour "off-drug" data were collected. "On-drug" assessment was conducted after 4-5 weeks of droxidopa treatment (mean dose, 444 mg, three times daily). Ambulatory monitoring off drug revealed that 90% of patients already had abnormalities in the circadian BP profile and did not meet criteria for normal nocturnal BP dipping. On treatment, both overall mean 24-hour systolic and diastolic BPs were higher compared to off drug (137/81 mm Hg vs. 129/76 mm Hg; P = .017/.002). Mean daytime systolic BP was significantly higher with droxidopa (8.4 ± 3.1 mm Hg; P = .014). Although nocturnal BP was not significantly higher on droxidopa versus off treatment (P = .122), increases in nocturnal (supine) BP ≥10 mm Hg were observed in four cases (22%). Severe supine systolic hypertensive readings at night (>200 mm Hg) were captured in one case and only while on treatment. These data demonstrate that ambulatory BP monitoring is useful to evaluate the circadian BP profile after initiating treatment with a pressor agent.
Collapse
Affiliation(s)
- Horacio Kaufmann
- Department of Neurology, New York University, New York, NY, USA.
| | | | | | | | - William B White
- Division of Hypertension and Clinical Pharmacology, Calhoun Cardiology Center, University of Connecticut School of Medicine, Farmington, CT, USA
| |
Collapse
|
121
|
In Sinn D, Gibbons CH. Pathophysiology and Treatment of Orthostatic Hypotension in Parkinsonian Disorders. Curr Treat Options Neurol 2016; 18:28. [DOI: 10.1007/s11940-016-0410-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
|
122
|
McDonald C, Newton JL, Burn DJ. Orthostatic hypotension and cognitive impairment in Parkinson's disease: Causation or association? Mov Disord 2016; 31:937-46. [DOI: 10.1002/mds.26632] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Revised: 03/08/2016] [Accepted: 03/09/2016] [Indexed: 12/24/2022] Open
Affiliation(s)
- Claire McDonald
- Institute of Cellular Medicine; Newcastle University; Newcastle upon Tyne UK
- Newcastle upon Tyne Hospitals NHS Foundation Trust; Newcastle UK
| | - Julia L. Newton
- Institute of Cellular Medicine; Newcastle University; Newcastle upon Tyne UK
- Newcastle upon Tyne Hospitals NHS Foundation Trust; Newcastle UK
| | - David J. Burn
- Newcastle upon Tyne Hospitals NHS Foundation Trust; Newcastle UK
- Institute of Neuroscience; Newcastle University; Newcastle upon Tyne UK
| |
Collapse
|
123
|
Lee AKY, Krahn AD. Evaluation of syncope: focus on diagnosis and treatment of neurally mediated syncope. Expert Rev Cardiovasc Ther 2016; 14:725-36. [DOI: 10.1586/14779072.2016.1164034] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
124
|
Palma JA, Norcliffe-Kaufmann L, Kaufmann H. An orthostatic hypotension mimic: The inebriation-like syndrome in Parkinson disease. Mov Disord 2016; 31:598-600. [PMID: 26879239 DOI: 10.1002/mds.26516] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Revised: 11/17/2015] [Accepted: 11/19/2015] [Indexed: 01/06/2023] Open
Affiliation(s)
- Jose-Alberto Palma
- Dysautonomia Center, Department of Neurology, New York University School of Medicine, New York, New York, USA
| | - Lucy Norcliffe-Kaufmann
- Dysautonomia Center, Department of Neurology, New York University School of Medicine, New York, New York, USA
| | - Horacio Kaufmann
- Dysautonomia Center, Department of Neurology, New York University School of Medicine, New York, New York, USA
| |
Collapse
|
125
|
Perez-Lloret S. Investigational drugs for autonomic dysfunction in Parkinson’s disease. Expert Opin Investig Drugs 2016; 25:259-62. [DOI: 10.1517/13543784.2016.1135128] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
|
126
|
Autonomic dysfunction in subjects at high risk for Parkinson's disease. J Neurol 2015; 262:2643-52. [PMID: 26530505 DOI: 10.1007/s00415-015-7888-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Revised: 08/21/2015] [Accepted: 08/22/2015] [Indexed: 12/15/2022]
Abstract
Aim of this project was to evaluate autonomic dysfunction in subjects proposed to be at high risk to develop Parkinson's disease (PD) compared to control subjects and PD patients at different disease stages. Combinations of substantia nigra hyperechogenicity (SN+) assessed by transcranial ultrasound (TCS), hyposmia, lifetime prevalence of depression and mild PD-specific motor signs were used to identify subjects at high risk for motor Parkinson's disease (HR-PD). Supine and standing blood pressure (BP), hearth rate (HR), orthostatic, urinary, sexual and bowel symptoms were evaluated in HR-PD, healthy control subjects and PD patients, divided into mild and advanced stages. The study group consisted of 113 PD patients (mild PD n = 71, advanced PD, n = 42), 40 HR-PD individuals and 50 controls. Compared to controls, HR-PD subjects complained more often about urinary (p = 0.002) and bowel dysfunction (p = 0.001) and had a higher diastolic BP drop after standing (p = 0.01). The cumulative number of autonomic symptoms differentiated PD as well as HR-PD significantly from controls (p < 0.001). Advanced PD patients presented often and severe orthostatic symptoms, not significantly different from mild PD after concomitant medication correction. Our results support the presence of urinary and bowel dysfunction in subjects at high risk for motor PD. Presence and severity of orthostatic symptoms was higher during stages and increase in advanced stages, at least partly due to increase in dopaminergic and conflicting medication. Understanding the progression of non-motor aspects in PD might offer the possibility to use them as targets for disease-modifying therapies.
Collapse
|
127
|
Indelicato E, Fanciulli A, Poewe W, Antonini A, Pontieri FE, Wenning GK. Cerebral autoregulation and white matter lesions in Parkinson's disease and multiple system atrophy. Parkinsonism Relat Disord 2015; 21:1393-7. [PMID: 26578037 DOI: 10.1016/j.parkreldis.2015.10.018] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2015] [Revised: 09/23/2015] [Accepted: 10/29/2015] [Indexed: 11/28/2022]
Abstract
Cerebral autoregulation is a complex homeostatic process which ensures constant brain blood supply, despite continuous blood pressure fluctuations. Recent evidence suggests that in Parkinson's disease (PD) and multiple system atrophy (MSA) this process is maintained in a broadened range of blood pressure values, consistent with an adaptive mechanism to increase tolerance to orthostatic hypotension. In PD and MSA orthostatic hypotension may be accompanied by supine hypertension which has been recently linked with cerebral white matter lesions in these conditions. We hypothesize that cerebral autoregulation adaptation to chronic orthostatic hypotension may be directly related with an increase susceptibility to hypertensive peaks. Evaluation of cerebral autoregulatory behavior may thus represent a novel approach to simultaneously target orthostatic symptoms and silent end-organ damage in alpha-synucleinopathies, with a beneficial impact on cerebrovascular and cognitive outcome.
Collapse
Affiliation(s)
- Elisabetta Indelicato
- Department of Neuroscience, Mental Health and Sensory Organs, "Sapienza" University of Rome, Via di Grottarossa 1035, 00189 Rome, Italy; IRCCS Santa Lucia Foundation, Via Ardeatina 306, 00179 Rome, Italy.
| | - Alessandra Fanciulli
- Department of Neuroscience, Mental Health and Sensory Organs, "Sapienza" University of Rome, Via di Grottarossa 1035, 00189 Rome, Italy; Department of Neurology, Innsbruck Medical University, Anichstraße 35, 6020 Innsbruck, Austria
| | - Werner Poewe
- Department of Neurology, Innsbruck Medical University, Anichstraße 35, 6020 Innsbruck, Austria
| | - Angelo Antonini
- IRCCS Ospedale San Camillo, Via Alberoni 70, 30126 Venice, Italy
| | - Francesco E Pontieri
- Department of Neuroscience, Mental Health and Sensory Organs, "Sapienza" University of Rome, Via di Grottarossa 1035, 00189 Rome, Italy; IRCCS Santa Lucia Foundation, Via Ardeatina 306, 00179 Rome, Italy
| | - Gregor K Wenning
- Department of Neurology, Innsbruck Medical University, Anichstraße 35, 6020 Innsbruck, Austria
| |
Collapse
|
128
|
Abstract
Orthostatic hypotension (OH) leads to a significant number of hospitalizations each year, and is associated with significant morbidity and mortality among affected individuals. Given the increased risk for cardiovascular events and falls, it is important to identify the underlying etiology of OH and to choose appropriate therapeutic agents. OH can be non-neurogenic or neurogenic (arising from a central or peripheral lesion). The initial evaluation includes orthostatic vital signs, complete history and a physical examination. Patients should also be evaluated for concomitant symptoms of post-prandial hypotension and supine hypertension. Non-pharmacologic interventions are the first step for treatment of OH. The appropriate selection of medications can also help with symptomatic relief. This review highlights the pathophysiology, clinical features, diagnostic work-up and treatment of patients with neurogenic OH.
Collapse
Affiliation(s)
- Pearl K Jones
- a 1 Department of Neurology, University of Texas Health Sciences Center, San Antonio, TX, USA
| | - Brett H Shaw
- b 2 Department of Cardiac Science, Libin Cardiovascular Institute, University of Calgary, Calgary, AB, Canada
| | - Satish R Raj
- b 2 Department of Cardiac Science, Libin Cardiovascular Institute, University of Calgary, Calgary, AB, Canada.,c 3 Department of Medicine, Division of Clinical Pharmacology, Autonomic Dysfunction Center, Vanderbilt University, Nashville, Tennessee, USA
| |
Collapse
|
129
|
Abstract
Neurogenic orthostatic hypotension (nOH) is a fall in blood pressure (BP) on standing due to reduced norepinephrine release from sympathetic nerve terminals. nOH is a feature of several neurological disorders that affect the autonomic nervous system, most notably Parkinson disease (PD), multiple system atrophy (MSA), pure autonomic failure (PAF), and other autonomic neuropathies. Droxidopa, an orally active synthetic amino acid that is converted to norepinephrine by the enzyme aromatic L-amino acid decarboxylase (dopa-decarboxylase), was recently approved by the FDA for the short-term treatment of nOH. It is presumed to raise BP by acting at the neurovascular junction to increase vascular tone. This article summarizes the pharmacological properties of droxidopa, its mechanism of action, and the efficacy and safety results of clinical trials.
Collapse
Affiliation(s)
- Horacio Kaufmann
- Department of Neurology, New York University School of Medicine, New York, NY, USA
| | | | | |
Collapse
|