What do you do for a patient with Parkinson's Disease and orthostatic hypotension who has failed midodrine, fludrocortisone, droxidopa, pyridostigmine, and atomoxetine?

I would not recommend using amantadine in this situation as it is known to worsen orthostatic hypotension (Perez-Lloret et al., PMID 22336566). This is a tricky situation, and if the patient has failed all of these medications, I would consider an alternate diagnosis, specifically MSA, especially if...

I would approach this in several ways.

1. Conservative strategies to increase blood pressure, including compression stockings (thigh high), abdominal binder, salt supplementation, good hydration, etc
2. Stop all meds that could be reducing blood pressure (don’t forget meds for prostate problems)
3. Use thos...

There’s a lot to consider in this kind of situation. Autonomic failure in PD can be incredibly severe and hard to manage.

Unclear what they may be on now, but it’s often the case that multiple agents are necessary. So don’t hesitate to have them in a pressor, pyridostigmine, and fludrocortisone.

Dont...