SB is an 81 year old male with a 11-year history of Parkinson's disease (PD) beginning in 2014. In June 2018 he experienced symptomatic nOH. In November 2018 despite non-pharmacologic measures, symptoms persisted (Sitting: 103/67 mmHg; Standing: 82/60 mmHg) so he started Midodrine 2.5 mg (morning/noon). In February 2019 (Sitting: 108/78 mmHg; Standing: 100/72 mmHg), Fludrocortisone 0.1 mg was added. In December 2019 (Sitting: 128/70 mmHg; Standing: 102/68 mmHg), Midodrine was increased to 5 mg (morning/noon) and 2.5 mg (early evening). In April 2020, Midodrine was further increased to 15 mg (morning/noon) and 10 mg (early evening). In June 2020, he was seen at an autonomic center where they recommended adding Pyridostigmine 60 mg, titrating up to a TID regimen (Sitting: 143/98 mmHg; Standing: 77/53 mmHg). He remained asymptomatic until two syncopal episodes secondary to alcohol use occurred in December 2021 and January 2023. He remained stable throughout 2024. After worsening of PD motor symptoms, he began Foscarbidopa/Foslevodopa SQ infusion in July 2025. 

After titration of Foscarbidopa/Foslevodopa, his blood pressure was persistently elevated. To address this, Fludrocortisone was discontinued and Midodrine was weaned off. By August 2025, his blood pressure normalized while remaining on Pyridostigmine monotherapy. He was asymptomatic but developed hallucinations associated with the use of Foscarbidopa/Foslevodopa in September 2025. By October 2025, Foscarbidopa/Foslevodopa was discontinued. One day later, he began having BP drops (Sitting: 75/54 mmHg) resulting in the reinitiation of Midodrine.