MEDICAL HISTORY MAY REVEAL WHICH PATIENTS ARE AT RISK FOR nOH

Consider evaluating a patient's full medical history to help rule out potential causes for symptoms related to neurogenic orthostatic hypotension (nOH), including other types of orthostatic hypotension or medication classes that have been linked to exacerbated orthostatic hypotension.1-4

Patient groups at increased risk for nOH1-4:

  • Patients with unexplained syncope
  • Patients experiencing postural dizziness or nonspecific symptoms that only occur upon standing and diminish upon sitting or lying down
  • Patients with a pre-existing neurodegenerative disorder such as Parkinson's disease, multiple system atrophy, or pure autonomic failure
  • Patients with autonomic neuropathy
  • Elderly patients

ORTHOSTATIC HYPOTENSION (OH) TYPES AND CAUSES

COMMONLY USED TESTS TO HELP RULE OUT OTHER CAUSES FOR SYMPTOMATIC EPISODES1,8:

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

SCREENING QUESTIONS MAY BE USEFUL IN IDENTIFYING PATIENTS EXPERIENCING SYMPTOMS OF nOH

Patients living with nOH may dismiss their symptoms as being associated with their pre-existing neurodegenerative disorder.5  Consider the following screening questions, noting frequency, severity, and how long patients can stand1,3,7:

  • Do you feel dizzy or lightheaded upon standing?
  • Have you fainted/blacked out recently?
  • Have you recently experienced a fall?
  • Are the symptoms worse in the morning or after meals?
  • Do symptoms improve or disappear when you sit or lay down?

“It was a relief to put a name with the symptoms.”—Linda, nOH care partner

VARIOUS CLASSES OF MEDICATIONS MAY CAUSE OR WORSEN SYMPTOMS OF nOH

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.1,4,7,9 Review the following classes of medications and consider reducing or modifying the current medications taken, as appropriate.1,3,4,7,10

  • Dopaminergic agents
  • Antidepressants (particularly tricyclic agents)*
  • Anticholinergics
  • Antihypertensive 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. 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. 
  3. Goldstein DS, Sharabi Y. Neurogenic orthostatic hypotension: a pathophysiological approach. Circulation. 2009;119(1):139-146. 
  4. Bradley JG. Davis KA. Orthostatic hypotension. Am Fam Physician. 2003;68(12):2393-2398.
  5. Low PA. Neurogenic orthostatic hypotension: pathophysiology and diagnosis. Am J Manag Care. 2015;21(suppl 13):s248-s257. 
  6. Freeman R. Neurogenic orthostatic hypotension. N Engl J Med. 2008;358(6):615-624.
  7. Palma JA. Kaufmann H. Epidemiology, diagnosis, and management of neurogenic orthostatic hypotension. Mov Disord Clin Pract. 2017:4(3):298-308.
  8. Lanier JB, Mote MB, Clay EC. Evaluation and management of orthostatic hypotension. Am Fam Physician. 2011;84(5):527-536.
  9. Mathias CJ. Autonomic diseases: clinical features and laboratory evaluation. J Neurol Neurosurg Psychiatry. 2003;74(suppl 3):iii31-iii41.
  10. Isaacson SH. Managed care approach to the treatment of neurogenic orthostatic hypotension. Am J Manag Care. 2015;21(suppl 13):s258-s268.