orthostatic hypotension

My father is 84, diagnosed with PD >5 years ago. Last 4 years Madopar 100/25 QID, and additional slow release Madopar introduced last year as well. Mild PD, tremor to right hand some neck rigidity and stopped cervical/neck area. No shuffling, Recent knee replacement – pain management local anaesthetic in knee for 24 hours. Over last 4 days whilst hospitalised significant postural drop of bw 40-70. Commenced on flurinef 100 daily continued hypotension resulting in 3 met codes, flurinef increased to 200 daily hypotension persists. What would you suggest to assist with this managment. Is this progression of the disease or more induced due to surgery and hosptial stay?

Dr. Sanchez-Ramos said...

I don’t believe the dose of Florinef is 100! It comes as 0.1 mg tablets, so perhaps you mean he has bee given up to two tablets per day (0.2 mg).
In any case, those severe drops in blood pressure are often seen in the Shy-Drager form of atypical PD (multiple system atrophy). In dealing with orthostatic hypotension, these are the steps I usually recommend:
1st step is to make sure he drinks salt containing beverages (Gatorade), providing he does not suffer from congestive heart disease. 2nd step is to have him wear pressure hose (thigh-high) all day and to sleep at night with head elevated at least 30 degrees from the horizontal. 3rd step is to take florinef, typically 0.1 mg at bedtime. 4th step is to add a vasopressor in the daytime such as Midodrine (providing his heath is OK). All of this requires close medical supervison. Finally he may need to decrease his Sinemet or dopamine medications because they tend to lower blood pressure.