MEDICAL HISTORY MAY HELP EXCLUDE OTHER CAUSES FOR SYMPTOMS ASSOCIATED WITH nOH

Neurogenic orthostatic hypotension (nOH) is a subset of orthostatic hypotension in patients with autonomic dysfunction.1-3 Several characteristics distinguish nOH from non-neurogenic orthostatic hypotension, including cause. Patients with nOH experience drops in blood pressure as a result of a norepinephrine deficiency not present in non-neurogenic orthostatic hypotension.3-5 Consider evaluating a patient’s full medical history to help rule out potential causes for nOH-related symptoms, including other types of orthostatic hypotension or medication classes that have been linked to exacerbated orthostatic hypotension.1,2,6-8

COMMONLY USED TESTS TO HELP RULE OUT OTHER CAUSES FOR SYMPTOMATIC EPISODES1,9:

  • Electrocardiogram
  • Complete blood count
  • Basic metabolic panel (sodium, potassium, chloride, bicarbonate, blood urea nitrogren, creatinine, and fasting glucose)
  • B12 level, methylmalonic acid

VARIOUS CLASSES OF MEDICATIONS MAY CAUSE nOH-LIKE SYMPTOMS IN PATIENTS

nOH patients tend to be elderly and with a higher rate of polypharmacy. It may be possible that a patient’s medications could be causing symptoms of orthostatic hypotension.1,6,7,10 Review the following classes of medications and consider reducing or modifying the current medications taken, as appropriate1,4,6,7,11:

  • Dopaminergic agents
  • Antidepressants (particularly tricyclic agents)*
  • Anticholinergics
  • Anti-hypertensive agents

*Agents that may cause more significant worsening of orthostatic hypotension/nOH.

References: 1. Gibbons CH, Schmidt P, Biaggioni I, et al. The recommendations of a consensus panel for the screening, diagnosis, and treatment of neurogenic orthostatic hypotension and associated supine hypertension. J Neurol. 2017;264(8):1567-1582. 2. Kaufmann H, Norcliffe-Kaufmann L, Palma JA. Droxidopa in neurogenic orthostatic hypotension. Expert Rev Cardiovasc Ther. 2015;13(8):875-891. 3. Freeman R, Wieling W, Axelrod FB, et al. Consensus statement on the definition of orthostatic hypotension, neurally mediated syncope and the postural tachycardia syndrome. Clin Auton Res. 2011;21(2):69-72. 4. Low PA. Neurogenic orthostatic hypotension: pathophysiology and diagnosis. Am J Manag Care. 2015;21(suppl 13):s248-s257. 5. Isaacson SH, Skettini J. Neurogenic orthostatic hypotension in Parkinson’s disease: evaluation, management, and emerging role of droxidopa. Vasc Health Risk Manag. 2014;10:169-176. 6. Freeman R. Neurogenic orthostatic hypotension. N Engl J Med. 2008;358(6):615-624. 7. Shibao C, Lipsitz LA, Biaggioni I. Evaluation and treatment of orthostatic hypotension. J Am Soc Hypertens. 2013;7(4):317-324. 8. Goldstein DS, Sharabi Y. Neurogenic orthostatic hypotension: a pathophysiological approach. Circulation. 2009;119(1):139-146. 9. Lanier JB, Mote MB, Clay EC. Evaluation and management of orthostatic hypotension. Am Fam Physician. 2011;84(5):527-536. 10. Isaacson SH. Managed care approach to the treatment of neurogenic orthostatic hypotension. Am J Manag Care. 2015;21(suppl 13):s258-s268. 11. Mathias CJ. Autonomic diseases: clinical features and laboratory evaluation. J Neurol Neurosurg Psychiatry. 2003;74(suppl 3):iii31-iii41.