Pharmacology of orthostatic hypotension in Parkinson’s disease: from pathophysiology to management

Orthostatic hypotension is highly prevalent in the elderly, and affects up to 20% of patients with Parkinson's disease. Pharmacological approaches help to demonstrate that Parkinson's disease is a primary autonomic failure with involvement of the peripheral autonomic nervous system as shown by decreased (123)I meta-iodobenzylguanidine cardiac uptake and preserved growth hormone response to clonidine. No specific clinical trial has evaluated efficacy of antihypotensive drugs in Parkinson's disease. End point of treatment should be a reduction in postural symptoms. Midodrine (Proamatin), Roberts Pharmaceutical), a vasoconstrictor and fludrocortisone (Florinef), Bristol-Myers Squibb), a volume expander are first choice drugs. No data are available on their effects on orthostatic hypotension-related morbidity. The usefulness of other drugs remains to be demonstrated. This review will highlight the importance of nonpharmacological measures in the management of orthostatic hypotension in Parkinson's disease.