Levodopa‐induced orthostatic hypotension in parkinsonism: A red flag of autonomic failure

Abstract

AbstractBackground and purposeLevodopa (LD) is the main treatment for parkinsonism, but its use may be limited by a potential hypotensive effect.MethodsWe evaluated the cardiovascular effect of LD performing head‐up tilt test (HUTT) before and 60 min after 100/25 mg LD/dopa‐decarboxylase inhibitor (pre‐LD vs. post‐LD HUTT) in 164 patients with parkinsonism on chronic LD treatment. Features predictive of LD‐induced orthostatic hypotension (OH) were assessed by logistic regression analysis.ResultsBasal supine blood pressure (BP) and heart rate (HR) decreased after LD. During post‐LD HUTT, BP drop and HR increase were significantly greater than at pre‐LD HUTT. Thirty‐eight percent of patients had OH at post‐LD HUTT compared to 22% of patients presenting OH at pre‐LD HUTT (p < 0.001). Risk factors for LD‐induced/worsened OH were pre‐LD OH (odds ratio [OR] = 36, 95% confidence interval [CI] = 10–131), absence of overshoot at Valsalva maneuver (OR = 9, 95% CI = 4–20), and pathological Valsalva ratio (OR = 6, 95% CI = 2–15).ConclusionsLD administration caused/worsened hypotension in both supine and orthostatic conditions. Patients with cardiovascular autonomic failure had a higher risk of developing LD‐induced OH. In clinical practice, LD‐induced OH could represent a red flag for cardiovascular autonomic failure.