Orthostatic hypotension in patients with Parkinson's disease - Pathophysiology and management
Orthostatic hypotension in patients with Parkinson's disease - Pathophysiology and management
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DOI：
10.2165/00002512-200118070-00003
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发表时间：
2001-01-01
期刊：
影响因子：
2.8
通讯作者：
Montastruc, JL
中科院分区：
文献类型：
--
作者：
Senard, JM;Brefel-Courbon, C;Montastruc, JL
直立性低血压在老年患者中很常见，现在被认为是认知能力下降和死亡率的重要预后因素。在帕金森病患者中，症状性体位性低血压的患病率可能高达20%。有两个因素可以解释这种高流行率。首先，多巴胺能药物可能诱发或加重直立性低血压。其次，帕金森病是原发性自主神经功能衰竭的原因，涉及外周自主神经系统，如路易体的普遍分布和碘苄胍[间碘苄胍（MIBG）]心脏摄取减少所示。这些病理和药理学特征清楚地将帕金森病的自主神经功能衰竭与多系统萎缩区分开来。如果自主神经功能异常出现在疾病的第一阶段，早期发作（在第一年内）的症状性直立性低血压的过程中帕金森病可以被认为是一个排除标准的特发性帕金森病。没有具体的临床试验评价抗水肿药物的效果在帕金森病患者，因此没有具体的治疗策略可以推荐。帕金森病患者体位性低血压的管理应始终从患者教育和非药物治疗开始。药物治疗应该保留给那些没有从非药物治疗中获益的有症状的患者。在现有药物中，最常用的是α（1）-肾上腺素能激动剂（主要是米多君）或血浆容量扩张剂（主要是氟氢可的松）。还有一些药物目前正在研究中，如育亨宾和屈昔多巴。其他药物如去氨加压素或奥曲肽在某些情况下可能是感兴趣的。多潘立酮被广泛用于帕金森综合征患者，但对直立性低血压无明显疗效。
Orthostatic hypotension is common in elderly patients, and is now considered to be an important prognostic factor for cognitive decline and mortality. In patients with Parkinson's disease, the prevalence of symptomatic orthostatic hypotension may be as high as 20%. Two factors could explain this high prevalence. First, dopaminergic drugs may induce or worsen orthostatic hypotension. Secondly, Parkinson's disease is a cause of primary autonomic failure with an involvement of the peripheral autonomic system as shown by the ubiquitous distribution of Lewy bodies and reduced iobenguane [metaiodobenzylguanidine (MIBG)I cardiac uptake. These pathological and pharmacological characteristics clearly differentiate autonomic failure of Parkinson's disease from multiple system atrophy. If autonomic abnormalities appear to be present from the first stage of the disease, early onset (within the first year) of symptomatic orthostatic hypotension in the course of parkinsonism can be considered as an exclusion criteria for idiopathic Parkinson's disease.No specific clinical trials have evaluated the effects of antihypotensive drugs in patients with Parkinson's disease and thus no specific therapeutic strategy can be recommended. The management of orthostatic hypotension in patients with Parkinson's disease should always start with patient education and nonpharmacological treatment. Drug therapy should be reserved for symptomatic patients who do not get benefit from nonpharmacological management. Among the available drugs, alpha (1)-adrenergic agonists (mainly midodrine) or plasma volume expanders (mainly fludrocortisone) are the most frequently used. There are also some drugs that are currently investigational such as yohimbine and droxidopa. Other drugs such as desmopressin or octreotide may be of interest in some situations. Domperidone is widely used in patients with parkinsonism with no proven effect on orthostatic hypotension.