The recommendations of a consensus panel for the screening, diagnosis, and treatment of neurogenic orthostatic hypotension and associated supine hypertension

Christopher H Gibbons, Peter Schmidt, Italo Biaggioni, Camille Frazier-Mills, Roy Freeman, Stuart Isaacson, Beverly Karabin, Louis Kuritzky, Mark Lew, Phillip Low, Ali Mehdirad, Satish R Raj, Steven Vernino, Horacio Kaufmann, Christopher H Gibbons, Peter Schmidt, Italo Biaggioni, Camille Frazier-Mills, Roy Freeman, Stuart Isaacson, Beverly Karabin, Louis Kuritzky, Mark Lew, Phillip Low, Ali Mehdirad, Satish R Raj, Steven Vernino, Horacio Kaufmann

Abstract

Neurogenic orthostatic hypotension (nOH) is common in patients with neurodegenerative disorders such as Parkinson's disease, multiple system atrophy, pure autonomic failure, dementia with Lewy bodies, and peripheral neuropathies including amyloid or diabetic neuropathy. Due to the frequency of nOH in the aging population, clinicians need to be well informed about its diagnosis and management. To date, studies of nOH have used different outcome measures and various methods of diagnosis, thereby preventing the generation of evidence-based guidelines to direct clinicians towards 'best practices' when treating patients with nOH and associated supine hypertension. To address these issues, the American Autonomic Society and the National Parkinson Foundation initiated a project to develop a statement of recommendations beginning with a consensus panel meeting in Boston on November 7, 2015, with continued communications and contributions to the recommendations through October of 2016. This paper summarizes the panel members' discussions held during the initial meeting along with continued deliberations among the panel members and provides essential recommendations based upon best available evidence as well as expert opinion for the (1) screening, (2) diagnosis, (3) treatment of nOH, and (4) diagnosis and treatment of associated supine hypertension.

Keywords: Autonomic dysfunction; Droxidopa; Fludrocortisone; Midodrine; Neurogenic orthostatic hypotension; Supine hypertension.

Conflict of interest statement

Dr. Gibbons is on advisory boards for Pfizer and Lundbeck, is on data safety monitoring boards for Janssen and Astellas, and received research funding from Celgene and Grifols Inc. Dr. Schmidt has nothing to disclose. Dr. Biaggioni served as a clinical trial investigator for Lundbeck and is a consultant/advisor for Shire Pharmaceutical and Lundbeck. Dr. Frazier-Mills is on an advisory board for Lundbeck. Dr. Freeman is on an advisory board for Lundbeck. Dr. Isaacson has received honoraria for CME, is a consultant/advisor, received research funding/grants, and/or is a promotional speaker on behalf of AbbVie, Acadia Pharmaceuticals, Adamas Pharmaceuticals, Addex Therapeutics, Allergan, Allon Therapeutics, Amarantus Bioscience, AstraZeneca, Auspex Pharmaceuticals, Biotie Therapies, Britannia Pharmaceuticals, Chelsea Therapeutics, Civitas Therapeutics, Cynapsus Therapeutics, Eisai, GE Healthcare, GSK, Impax Pharmaceuticals, Ipsen, Kyowa, Lilly, Lundbeck, Merck, Schering-Plough, Medtronics, Merz, Michael J Fox Foundation, Novartis, Neurocrine Biosciences, NIH, Novartis, Orion, Parkinson Study Group, Pfizer, Phytopharm Plc, Purdue Pharma, Roche, Santhera Pharmaceuticals, Serono, Shire, Teva, UCB, US World Meds, Vanda Pharmaceuticals, and Xenoport. Dr. Karabin is a speaker and consultant for Lundbeck. Dr. Kuritzky is a speaker, consultant, and on an advisory board for Lundbeck. Dr. Lew is a consultant/advisor for Teva, US World Meds, UCB, Acadia, Auspex, Lundbeck, Abbvie, Impax, Cynapsus, Adamas, and Jazz; he is a speaker for Teva, USWM, UCB Pharma, Lundbeck, Acadia, and Impax; and he is a clinical researcher for Parkinson’s Study Group, Michael J. Fox Foundation, Civitas, Biotie, Intec Pharma, Neuroderm, the United States National Institutes of Health (NIH), and Enterin. Dr. Low has nothing to disclose. Dr. Mehdirad is a speaker for Lundbeck. Dr. Raj is on an advisory board for Lundbeck, is a consultant for GE Healthcare, is a clinical trial investigator for Medtronic and Bristol Myers Squibb, and received research funding from the Canadian Institutes of Health Research (CIHR). Dr. Vernino is on an advisory board and speaker bureau for Lundbeck and is a scientific consultant for Athena Diagnostics (a division of Quest). Dr. Kaufmann is on an advisory board for Lundbeck, ICE for Astra Zeneca, and has received research funding from the United States Food and Drug Administration (FDA) and NIH.

Figures

Fig. 1
Fig. 1
Stepwise approach to the diagnosis of nOH
Fig. 2
Fig. 2
A 4-step process for treating nOH

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