Droxidopa for neurogenic orthostatic hypotension

Introduction: Neurogenic orthostatic hypotension is a disabling manifestation of autonomic failure seen in disorders such as multiple system atrophy, pure autonomic failure, Lewy body disease, Parkinson’s disease, autonomic neuropathies and dopamine β-hydroxylase deficiency.Areas covered: Droxidopa is an orally administered norepinephrine prodrug that was approved in the US in the year 2014 for the treatment of neurogenic orthostatic hypotension. This review examines the published pharmacodynamic, pharmacokinetic, safety and efficacy data including the results of phase II and phase III studies of droxidopa.Expert opinion: Droxidopa has been shown to have measurable clinical benefit in reducing the symptoms of neurogenic orthostatic hypotension, in particular postural lightheadedness despite its modest pressor effect, and it has been well-tolerated. As studies to date have demonstrated only short-term efficacy and safety, longer-term studies are needed to establish the durability of efficacy. An important safety concern is droxidopa’s potential to exacerbate supine hypertension, which commonly occurs in neurogenic orthostatic hypotension. Direct comparison studies are needed with other treatment approaches for neurogenic orthostatic hypotension.