Although HCPs treating patients at risk of nOH are well suited to recognize symptoms and facilitate discussions regarding nOH with patients and their caregivers (Fig. 1) [2, 3, 8, 9], they also need to understand potential communication challenges. Patients with nOH may hide or minimize their symptoms and not discuss them with their HCP unless the symptoms are severe . Further, patients may attribute the symptoms to the underlying neurodegenerative disease or other comorbidities, not realizing that nOH is a separate condition. Others may be concerned that reporting nOH symptoms or falls could lead to restrictions on their activities and ability to live independently . Patients may not always be forthcoming regarding nOH symptoms, and patient survey data have indicated that patients find the path to diagnosis challenging. Half of patients with nOH reported frustration with the diagnostic process, which may have included multiple HCP consultations before their eventual diagnosis (43% consulted ≥ 3 HCPs) . Increased awareness of these issues will better enable HCPs to diagnose and treat these bothersome symptoms.
When nOH is suspected, orthostatic vital signs should be taken to observe whether the BP drop is indicative of OH (≥ 20 mmHg systolic or ≥ 10 mmHg diastolic) [2, 3]. However, individual in-clinic evaluations of orthostatic vitals might not confirm OH, and an at-home BP and symptom diary may be required . This diary should include the time of each BP measurement and accompanying circumstances, such as recent meals, timing of medications, or exercise. In patients with PD, such a record can also be used to document “on” and “off” periods of dopaminergic medication, allowing the HCP a comprehensive view of the patient’s overall symptom experience. Even after initial recognition of OH/nOH, continued use of a symptom diary can be useful to guide and adjust the treatment plan over time.
Once the presence of OH has been established, HCPs should aim to reduce any non-neurogenic causes of OH (i.e., Fig. 1, Step 4). For example, the potential contributing effects of any concomitant medications should be considered. Patients with PD and other synucleinopathies are often treated with medications such as levodopa (or other dopaminergic agents) and monoamine oxidase inhibitors that are associated with hypotensive effects and may worsen nOH symptoms [2, 10]. Additionally, many other medications commonly used in older populations also have hypotensive effects, including drugs for hypertension, depression, erectile dysfunction, benign prostatic hyperplasia (BPH; alfuzosin or tamsulosin), or hair loss (minoxidil) . In consultation with the care team, use of these medications in patients with nOH should be modified if possible (e.g., dose reduction, adjustment of timing of use [particularly PD medications], discontinuation) without exacerbating the indicated conditions . Referral for specialized autonomic function testing may be appropriate if the diagnosis continues to be unclear.
When managing nOH symptoms, attaining a certain standing blood pressure is not necessary; rather, the goals of treatment should focus on patient outcomes, including decreasing nOH symptom burden, mitigating risk of falls and fall-related injuries, and improving the ability to function independently in daily activities . The precise treatment choices should be tailored to the individual patient’s needs and circumstances considering both non-pharmacologic and pharmacologic options.
Non-pharmacologic measures are an important component of nOH management, but patients may not recognize or readily implement these measures. For example, waist-high compression garments are effective for treating patients with nOH, but patients may be reluctant to wear them because they may find these compression garments uncomfortable (especially in warmer weather) . Patients may also be inadequately hydrated from use of diuretics or self-restricted fluid intake to reduce urinary urgency or frequency related to stress incontinence, BPH, or other bladder disorders [2, 11]. In these cases, HCPs can educate patients to encourage compliance and enlist the help of the caregiver if necessary.
Although non-pharmacologic measures are often used as the initial approach to treat nOH, implementing pharmacotherapy is often necessary for adequate relief of symptoms. Droxidopa and midodrine are approved by the US Food and Drug Administration to treat the symptoms of nOH and OH, respectively (Fig. 1) [8, 9]. Other agents (e.g., fludrocortisone, pyridostigmine) are commonly used off-label for the treatment of nOH [2, 12, 13] but have limited evidence of efficacy based on results from well-designed trials. Several comprehensive reviews on the management of nOH have been published in the past 3 years and are useful resources for detailed guidance and specific considerations of individual non-pharmacologic and pharmacologic interventions [2, 12, 13].