Successful Use of Octreotide for Refractory Postural Hypotension in a Patient With Parkinson’s Disease and Heart Failure With Preserved Ejection Fraction

Postural hypotension, particularly in patients with autonomic dysfunction secondary to Parkinson's disease, presents a complex therapeutic challenge, especially when standard treatments fail. We report the case of an elderly patient admitted to a UK district general hospital with worsening diarrhoea and profound postural hypotension. The patient's background included Parkinson's disease, heart failure with preserved ejection fraction (HFpEF), ulcerative colitis, type 2 diabetes mellitus, and other chronic comorbidities. Initial management involved standard pharmacological therapy with fludrocortisone and midodrine, titrated to maximum tolerated doses. Despite this, the patient remained significantly symptomatic, unable to sit upright or stand. Repeated lying and standing blood pressure measurements confirmed substantial postural drops, and physiotherapy input was limited by hemodynamic instability. Given the ongoing symptoms and potential risks of fluid overload in the setting of HFpEF, fludrocortisone was discontinued. Following local governance approval through the NHS trust's health board, required due to the unlicensed nature of octreotide for this indication, a stepwise titration of subcutaneous octreotide infusion was initiated. The patient exhibited progressive improvement at each stage, ultimately regaining the ability to sit and stand without orthostatic symptoms. Blood pressure readings stabilised in parallel with clinical recovery. This case highlights the potential utility of octreotide for managing refractory postural hypotension in the NHS, where standard treatments may be ineffective or contraindicated, and demonstrates the value of structured trust-level governance for safe off-label prescribing.