Vikas Kotagal, MD, Associate Professor of Neurology at University of Michigan Medical School
ANN ARBOR, MI — Treatments for orthostatic hypotension, a common, disabling symptom of Parkinson’s disease, can affect many therapeutic targets, so healthcare providers must coordinate care and optimize the sequence of treatment for those patients, particularly those with coexisting comorbidities, according to a recent review article.
The clinically focused review article published in Therapeutic Advances in Neurological Disorders was created for medical providers caring for patients with Parkinson’s disease and orthostatic hypotension. The article summarizes clinical features of orthostatic hypotension, pathophysiological considerations and pharmacological and nonpharmacological treatments that can improve symptoms. It also offers a proposed integrated approach to Parkinson’s disease patients with orthostatic hypotension and provides clinicians with a working understanding of management strategies for orthostatic hypotension that might help them in clinical practice.1
Study authors are affiliated with University of Michigan in Ann Arbor, MI, and VA Ann Arbor (MI) Health Care System. Both researchers are Parkinson’s disease-focused neurologists.
“More than 100,000 veterans have Parkinson disease (PD),” Vikas Kotagal, MD, associate professor of neurology at University of Michigan Medical School, told U.S. Medicine. “Symptoms of autonomic dysfunction, including lightheadedness, fatigue and dizziness, occur commonly in people with PD and play a big role in quality of life and functional independence. Medical providers including neurologists and primary care providers commonly need to dig deep in their bag of tricks to come up with solutions that help improve these symptoms for patients. This review provides a comprehensive review of treatments that VA clinicians may find particularly helpful when caring for patients with Parkinson disease.”
Orthostatic hypotension, which affects about 30% of people with Parkinson’s disease, is a substantial driver of discomfort and functional disability. The most common symptoms, in association with a drop in blood pressure, include lightheadedness or dizziness when adjusting posture from a horizontal or seated position to a standing position. Orthostatic hypotension leads to poor quality of life, increased fall risk, and might also be an independent marker for more aggressive disease progression. Clinicians caring for Parkinson’s patients can benefit from knowledge of different treatment options, including medications and nonpharmacological treatments, the researchers explained.
“One of the common challenging situations we encounter in clinic is to figure out how to improve lightheadedness symptoms in people with PD in a way that is 1) sustainable for the patient and 2) won’t worsen other health conditions,” said Kotagal, who is also a staff neurologist and associate chief of staff for research at VA Ann Arbor Healthcare System. “There often isn’t an easy solution, even for experienced specialists. This review grew out of lessons learned in these clinical experiences.”
The review evaluates pharmacological and nonpharmacological treatments and provides an integrated approach about how to deploy these treatments in clinical settings to deal with orthostatic hypotension. It also includes tables and figures that are written to help busy clinicians quickly and easily examine and use in clinical settings, Kotagal pointed out.
The investigators identified a range of orthostatic hypotension symptoms, including transient or persistent dizziness or lightheadedness immediately upon sitting or standing, imbalance when walking, “fuzzy” thinking (i.e., mildly impaired cognition) with standing that improves with sitting or lying down, blurry vision, pain in the posterior neck or bilateral shoulders, fatigue, headache and chest discomfort or shortness of breath when standing that is relieved by sitting down.
For primary neurodegenerative causes, orthostasis can be an early or even prodromal feature in synucleinopathies. For nonneurodegenerative causes, levodopa is the most used medication to treat Parkinson’s disease and can contribute to orthostatic hypotension symptoms through multiple overlapping mechanisms, the authors reported.
The researchers recommended screening for the condition using an assessment of orthostatic vital signs in people with Parkinson’s disease, presenting with classic and atypical symptoms of orthostatic hypotension, unexplained falls or syncope.
Underestimating Orthotic Hypotension
They cautioned that screening methods anchored only on common symptoms might underestimate the number of people with Parkinson’s disease who have orthostatic hypotension, especially if office-based blood pressure assessments are only available in seated-to-standing contexts. Home monitoring obtained first thing in the morning after lying for 5 minutes then standing 3 minutes or as symptoms develop during the day might be helpful, they added.
The study authors explained that a small group of patients with autonomic dysfunction have delayed orthostatic hypotension (drops occurring after 3 minutes), so continuous ambulatory blood pressure monitoring or autonomic testing could be considered if suspicion is high and other testing is negative. For patients with unrevealing assessments of orthostatic vital signs who have disabling orthostatic symptoms, referral for a tilt table test can help increase the sensitivity of a diagnostic work-up.
When orthostatic hypotension is identified, an important early step is to evaluate for an alternate explanation, including cardiovascular disease, vasodilatory effects of subacute infections and iatrogenic causes. Because of the prevalence of primary cardiac etiologies and infections, a full evaluation should be coordinated with the patient’s specialty providers. Also, it’s critical to closely examine the patient’s medications, including antihypertensive medications, the authors suggested.
They advised that clinicians must recognize the hypotensive effects of alpha blocking agents prescribed for benign prostatic hypertrophy as well as psychoactive medications, particularly tricyclic antidepressants and antipsychotics commonly used in patients with Parkinson’s disease psychosis. It’s essential to review the underlying indication of medications to limit polypharmacy, particularly in older patients, the researchers noted.
Patients with Parkinson’s disease and orthostatic hypotension should receive counseling about nonpharmacologic therapies to minimize blood pressure drops, even early in the symptomatic course while secondary causes are being evaluated.
The study noted that Important orthostatic hypotension lifestyle modifications include:
- increasing daily water intake,
- supplementing daily salt intake,
- avoiding potential triggers,
- changing behaviors to rise more slowly from a lying or seated position,
- learning and employing counter maneuvers, and
- considering compression garments.
As tolerated, physical exercise could help to improve muscle bulk, euglycemia and cardiac output, which all may improve the trajectory of symptoms. Patients with orthostatic hypotension also should be encouraged to eat small, frequent meals, avoid alcohol and avoid hot tub baths, showers, saunas or excessive high-intensity exercise, study authors suggested.
The investigators noted that patients with Parkinson’s disease have peripheral noradrenergic degeneration and low plasma norepinephrine, so midodrine and droxidopa, drugs that mimic elements of sympathetic tone, are the most effective.
They also recommended using midodrine as the first-line therapy for treatment of orthostatic hypotension in people with Parkinson’s disease and, after maximizing the dose, if symptoms persist and supine hypertension is not limiting, then clinicians should add low-dose fludrocortisone to enhance the effect. If this isn’t tolerated or symptoms persist, the authors recommended adding droxidopa. Midodrine can be continued or gradually tapered off, depending on the strength of clinical response to the droxidopa, according to the review.
- Wyant KJ, Kotagal V. Orthostatic hypotension in Parkinson’s disease: therapeutic considerations. Ther Adv Neurol Disord. 2025 Aug 19;18:17562864251363292. doi: 10.1177/17562864251363292. PMID: 40843281; PMCID: PMC12365467.
