Neurogenic orthostatic hypotension (OH) is a disabling disorder caused by impairment of the normal autonomic compensatory mechanisms that maintain upright blood pressure. Nonpharmacologic treatment is always the first step in the management of this condition, but a considerable number of patients will require pharmacologic therapies. Denervation hypersensitivity and impairment of baroreflex buffering makes these patients sensitive to small doses of pressor agents. Understanding the underlying pathophysiology can help in selecting between treatment options. In general, patients with low "sympathetic reserve", i.e., those with peripheral noradrenergic degeneration (pure autonomic failure, Parkinson's disease) and low plasma norepinephrine, tend to respond better to "norepinephrine replacers" (midodrine and droxidopa). On the other hand, patients with relatively preserved "sympathetic reserve", i.e., those with impaired central autonomic pathways but spared peripheral noradrenergic fibers (multiple system atrophy) and normal or slightly reduced plasma norepinephrine, tend to respond better to "norepinephrine enhancers" (pyridostigmine, atomoxetine, and yohimbine). There is, however, a spectrum of responses within these extremes, and treatment should be individualized. Other nonspecific treatments include fludrocortisone and octreotide. The presence of associated clinical conditions, such as supine hypertension, heart failure, postprandial hypotension, PD, MSA, and diabetes need to be considered in the pharmacologic management of these patients.

中文翻译：

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体位性低血压的药物治疗

神经源性直立性低血压 (OH) 是一种致残性疾病，由维持直立血压的正常自主神经代偿机制受损引起。非药物治疗始终是治疗这种疾病的第一步，但相当多的患者需要药物治疗。去神经超敏反应和压力反射缓冲受损使这些患者对小剂量升压剂敏感。了解潜在的病理生理学有助于在治疗方案之间进行选择。一般而言，“交感神经储备”低的患者，即外周去甲肾上腺素能变性（纯自主神经功能衰竭，帕金森病）和血浆去甲肾上腺素低的患者，往往对“去甲肾上腺素替代品”（米多君和屈昔多巴）反应更好。另一方面，“交感神经储备”相对保留的患者，即那些中枢自主神经通路受损但外周去甲肾上腺素能纤维（多系统萎缩）和正常或轻度减少血浆去甲肾上腺素的患者，往往对“去甲肾上腺素增强剂”反应更好。吡啶斯的明、托莫西汀和育亨宾）。然而，在这些极端情况下有一系列反应，治疗应该个体化。其他非特异性治疗包括氟氢可的松和奥曲肽。在对这些患者进行药物治疗时，需要考虑相关临床疾病的存在，例如仰卧位高血压、心力衰竭、餐后低血压、PD、MSA 和糖尿病。那些中枢自主神经通路受损但外周去甲肾上腺素能纤维（多系统萎缩）和正常或轻度减少的血浆去甲肾上腺素受损的人，往往对“去甲肾上腺素增强剂”（吡啶斯的明、托莫西汀和育亨宾）反应更好。然而，在这些极端情况下有一系列反应，治疗应该个体化。其他非特异性治疗包括氟氢可的松和奥曲肽。在对这些患者进行药物治疗时，需要考虑相关临床疾病的存在，例如仰卧位高血压、心力衰竭、餐后低血压、PD、MSA 和糖尿病。那些中枢自主神经通路受损但外周去甲肾上腺素能纤维（多系统萎缩）和正常或轻度减少的血浆去甲肾上腺素受损的人，往往对“去甲肾上腺素增强剂”（吡啶斯的明、托莫西汀和育亨宾）反应更好。然而，在这些极端情况下有一系列反应，治疗应该个体化。其他非特异性治疗包括氟氢可的松和奥曲肽。在对这些患者进行药物治疗时，需要考虑相关临床疾病的存在，例如仰卧位高血压、心力衰竭、餐后低血压、PD、MSA 和糖尿病。