Table 3:

Potential pharmacological interventions for orthostatic hypotension in patients with Lewy body dementia

	Dosing	Adverse effects	Comment
Midodrine	A 2·5–10 mg dose taken up to three times daily; avoid evening doses of midodrine; last dose should be taken at least 4 h before bed; monitor hepatic and renal function	Risk of supine hypertension	Several trials of patients with orthostatic hypotension (which have included patients with Parkinson’s disease) with some suggestion of efficacy9
Fludrocortisone	50–300 μg/day; titrate slowly and monitor electrolytes	Electrolyte disturbances, hypertension (especially supine), and oedema	A crossover clinical trial in 17 patients with Parkinson’s disease showed statistically significant subjective benefits with fludrocortisone compared to a range of non-pharmacological interventions70
Droxidopa	100–600 mg three times daily	Risk of supine hypertension, worsening heart disease or heart failure, and arrhythmias	A phase 3 trial of 162 patients with Parkinson’s disease with orthostatic hypotension reported subjective improvements in symptoms and a mean standing systolic blood pressure increase of 11·2 mm Hg vs 3–9 mm Hg compared with placebo;71 however, an interim analysis of a double-blind randomised controlled trial in patients with Parkinson’s disease did not show subjective benefits of droxidopa compared with placebo with regard to orthostatic hypotension symptoms,72 although a revised primary outcome in the full trial, which specifically focused on feelings of dizziness, light headedness, and feeling faint, suggested short-term benefits73