Hypotension, Orthostatic

Importance: Orthostatic hypotension is a common but underrecognized condition that increases with age and is associated with a lower quality of life, falls, and increased mortality. The frequent coexistence of supine hypertension and postprandial hypotension with orthostatic hypotension makes it a challenging condition to manage.

Observations: Testing for orthostatic hypotension should be done in patients with orthostatic symptoms (eg, vision changes and dizziness that occur only when upright and improve when seated or lying down), as well as asymptomatic patients in high-risk groups such as adults with frailty who are older than 70 years, individuals with neurodegenerative or autonomic disorders, and patients with unexplained falls. Patients with orthostatic hypotension should be screened for postprandial hypotension and supine hypertension to inform the treatment approach. Nonpharmacological strategies, such as medication review, increased salt and fluid intake, compression garments, and behavioral modifications, serve as fundamental approaches to treat orthostatic hypotension. Midodrine and droxidopa are the only US Food and Drug Administration-approved medications for orthostatic hypotension, but other medications (eg, fludrocortisone, atomoxetine, pyridostigmine) are used off label as part of an individualized treatment plan. Treatment targets in orthostatic hypotension are focused not on blood pressure measurements but on symptom relief and fall prevention.

Conclusions and relevance: All patients with orthostatic symptoms-along with other select patient groups-should be evaluated for orthostatic hypotension. Nonpharmacological treatments are first line, and medication decisions should be tailored based on clinical presentation and relevant comorbidities.

Author/s:

David Moloney, Ayman Youssef, Luis E. Okamoto

Peripheral Neuropathy: A Review

Megan George — Wed, 19 Nov 2025 22:20:00 +0000

Date Added:

November 19, 2025

Journal/Publication:

JAMA

Publication Date:

November 17, 2025

URL:

Peripheral Neuropathy: A Review

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

doi: 10.1001/jama.2025.19400

Keywords

neurology

neuralgia

Peripheral Nerves

MeSH

antidepressive agents

antidepressive agents, tricyclic

Charcot-Marie-Tooth Disease

blood glucose

Cisplatin

diabetic neuropathies

duloxetine hydrochloride

gabapentin

Hypesthesia

hypotension

Hypotension, Orthostatic

Reverse Transcriptase Inhibitors

Venlafaxine Hydrochloride

Peripheral Nerves

neuralgia

A review of the causes and treatment of the symptoms of peripheral neuropathy. Figure 2 and Table 1 may be particularly helpful. James W. Mold, MD, MPH

View

Importance Peripheral neuropathy, defined as damage to peripheral nerves, affects approximately 1% of adults worldwide. More than 200 causes of peripheral neuropathy exist, with symptoms ranging in severity from mild toe numbness to debilitating symptoms that can require a wheelchair. Diabetes is the most common cause of neuropathy, affecting approximately 206 million people worldwide.

Observations Peripheral neuropathy is typically length-dependent, which means that symptoms appear in the longest nerve axons (toes) and progress proximally over time. Peripheral neuropathy is typically symmetric and affects sensory axons more than motor axons. Diabetic neuropathy, which is often associated with both sensory symptoms, such as pain, tingling, or numbness; mild weakness; and autonomic symptoms, such as orthostatic hypotension, accounts for more than 50% of peripheral neuropathy in Western populations. Other causes of neuropathy include hereditary causes, such as Charcot-Marie-Tooth disease, toxic neuropathy from medications (chemotherapies [eg, cisplatin, paclitaxel, vincristine], amiodarone, or HIV nucleotide reverse transcriptase inhibitors [eg, stavudine, zalcitabine]); alcohol; vitamin deficiencies such as vitamin B12; and monoclonal gammopathies. Up to 27% of adults with neuropathy have no identifiable etiology for their neuropathy after diagnostic testing. Recommended initial testing includes blood glucose (for diabetes), serum B12 with metabolites (methylmalonic acid with or without homocysteine), and serum protein electrophoresis with immunofixation (for monoclonal gammopathies). First-line medications for neuropathic pain are the α2-δ calcium channel subunit ligands, such as gabapentin and pregabalin; serotonin norepinephrine reuptake inhibitors, such as duloxetine and venlafaxine; and tricyclic antidepressants, such as amitryptyline and nortriptyline. Pain often persists despite medical management. At least a 50% reduction in pain was observed in 38% of those with painful diabetic peripheral neuropathy receiving 1200 mg of gabapentin daily. Combination drug therapies for neuropathic pain may provide added benefit. The prognosis of peripheral neuropathy depends on its underlying cause, but complete reversal of nerve damage is uncommon even in cases for which there are available treatments.

Conclusions and Relevance Peripheral neuropathy affects approximately 1% of adults worldwide and may cause sensory, motor, and autonomic symptoms. Diabetes is the most common cause of peripheral neuropathy in Western countries. First-line therapies for neuropathic pain include gabapentin, pregabalin, duloxetine, and amitriptyline.

Author/s:

Michelle L. Mauermann, Nathan P. Staff

Parkinson disease primer, part 2: management of motor and nonmotor symptoms

Aubrey Delammermore — Thu, 23 Feb 2023 06:00:00 +0000

Date Added:

February 23, 2023

Journal/Publication:

Canadian Family Physician

Publication Date:

February 1, 2023

Issue:

Volume:

Pages:

91-96

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.46747/cfp.690291

Keywords

PMID (1):

36813521

MeSH

Levodopa

depression

Hypotension, Orthostatic

Physical Therapy Modalities

Sleep Wake Disorders

The second of a series of articles on management of Parkinson's Disease. James W. Mold, MD, MPH

Free full text

Objective To provide family physicians with an approach to the management of
motor and nonmotor symptoms of Parkinson disease (PD).
Sources of information Published guidelines on the management of PD were
reviewed. Database searches were conducted to retrieve relevant research
articles published between 2011 and 2021. Evidence levels ranged from I to III.
Main message Family physicians can play an important role in identifying and
treating motor and nonmotor symptoms of PD. Family physicians should initiate
levodopa treatment for motor symptoms if they affect function and if specialist
wait times are long, and they should be aware of basic titration approaches
and possible side effects of dopaminergic therapies. Abrupt withdrawal of
dopaminergic agents should be avoided. Nonmotor symptoms are common and
underrecognized and are a major factor in disability, quality of life, and risk of
hospitalization and poor outcomes for patients. Family physicians can manage
common autonomic symptoms such as orthostatic hypotension and constipation.
Family physicians can treat common neuropsychiatric symptoms such as
depression and sleep disorders, and they can help recognize and treat psychosis
and PD dementia. Referrals to physiotherapy, occupational therapy, speech
language therapy, and exercise groups are recommended to help preserve function.
Conclusion Patients with PD present with complex combinations of motor
and nonmotor symptoms. Family physicians should have basic knowledge of
dopaminergic treatments and their side effects. Family physicians can play
important roles in management of motor symptoms and particularly nonmotor
symptoms and can have a positive impact on patients’ quality of life. An
interdisciplinary approach involving specialty clinics and allied health experts
is an important part of management.

Author/s:

Frank, C., Chiu, R., Lee, J.