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Kulkarni S, Jenkins D, Dhar A, Mir F. Treating Lows: Management of Orthostatic Hypotension. J Cardiovasc Pharmacol 2024; 84:303-315. [PMID: 39027973 PMCID: PMC11368167 DOI: 10.1097/fjc.0000000000001597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 05/24/2024] [Indexed: 07/20/2024]
Abstract
ABSTRACT Orthostatic hypotension is a prevalent clinical condition, caused by heterogenous etiologies and associated with significant morbidity and mortality. Management is particularly challenging in patients with uncontrolled hypertension. A thorough assessment is needed to draw an appropriate management plan. The treatment aims to improve postural symptoms while minimizing side effects and reducing iatrogenic exacerbation of supine hypertension. A personalized management plan including rationalizing medications, patient education, identification, and avoidance of triggers, as well as nonpharmacological therapies such as compression devices, dietary modifications, and postural aids, make the first steps. Among pharmacological therapies, midodrine and fludrocortisone are the most prescribed and best studied; pyridostigmine, atomoxetine, and droxidopa are considered next. Yohimbine remains an investigational agent. A multidisciplinary team may be required in some patients with multiple comorbidities and polypharmacy. However, there is a lack of robust efficacy and safety evidence for all therapies. Building robust real-world and stratified clinical trials based on underlying pathophysiology may pave the way for further drug development and better clinical strategies and in this challenging unmet medical need.
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Affiliation(s)
- Spoorthy Kulkarni
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom
- Department of Clinical Pharmacology and Therapeutics, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Danny Jenkins
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom
- Lewisham and Greenwich NHS Foundation Trust, London, United Kingdom; and
| | - Arko Dhar
- University of Mississippi Medical Center, Jackson, Mississippi, United States of America
| | - Fraz Mir
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom
- Department of Clinical Pharmacology and Therapeutics, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
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2
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Chen YH, Chen CT. Atomoxetine for Intradialytic Hypotension in a Patient on Hemodialysis: A Case Report. Kidney Med 2024; 6:100840. [PMID: 38947771 PMCID: PMC11214336 DOI: 10.1016/j.xkme.2024.100840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/02/2024] Open
Abstract
Intradialytic hypotension significantly affects patient safety and clinical outcomes during hemodialysis. Despite various pharmacological and nonpharmacological interventions, effective management remains elusive. In this report, we detail a case of intradialytic hypotension in a male patient in his 40s, undergoing hemodialysis with a history of polycystic kidney disease. Eight years ago, the patient underwent bilateral nephrectomy because of a severe cystic infection, after which his systolic blood pressure (BP) persistently remained at 50-70 mm Hg during dialysis sessions. The initial treatment strategy for hypotension included fludrocortisone, midodrine, and prednisolone, leading to a slight temporary increase in BP, which subsequently declined. As the patient's condition deteriorated, the administration of norepinephrine or dopamine became necessary to sustain BP during dialysis. Given the patient's resistance to these treatments, a daily dose of 25 mg of atomoxetine was introduced. Following this treatment, there was a gradual improvement in the patient's vertigo, weakness, and BP. This case illustrates that low-dose atomoxetine can alleviate symptoms and elevate BP in patients experiencing severe intradialytic hypotension during hemodialysis.
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Affiliation(s)
- Yi-Hsin Chen
- Department of Nephrology, Taichung Tzu Chi Hospital, Taichung, Taiwan
- School of Medicine, Tzu Chi University, Hualien, Taiwan
- Department of Artificial Intelligence and Data Science, National Chung Hsing University, Taichung, Taiwan
| | - Chih-Tsung Chen
- Department of Nephrology, Taichung Tzu Chi Hospital, Taichung, Taiwan
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3
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Mwesigwa N, Shibao CA. Norepinephrine Reuptake Inhibition, an Emergent Treatment for Neurogenic Orthostatic Hypotension. Hypertension 2024; 81:1460-1466. [PMID: 38766862 PMCID: PMC11168875 DOI: 10.1161/hypertensionaha.124.22069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
The NET (norepinephrine transporter) is situated in the prejunctional plasma membrane of noradrenergic neurons. It is responsible for >90% of the norepinephrine uptake that is released in the autonomic neuroeffector junction. Inhibitors of this cell membrane transporter, known as norepinephrine reuptake inhibitors (NRIs), are commercially available for the treatment of depression and attention deficit hyperactivity disorder. These agents increase norepinephrine levels, potentiating its action in preganglionic and postganglionic adrenergic neurons, the latter through activation of α-1 adrenoreceptors. Previous studies found that patients with neurogenic orthostatic hypotension can improve standing blood pressure and reduce symptoms of neurogenic orthostatic hypotension after a single administration of the selective NRI atomoxetine. This effect was primarily observed in patients with impaired central autonomic pathways with otherwise normal postganglionic sympathetic fibers, known as multiple system atrophy. Likewise, patients with normal or high norepinephrine levels may benefit from NRIs. The long-term efficacy of NRIs for the treatment of neurogenic orthostatic hypotension-related symptoms is currently under investigation. In summary, an in-depth understanding of the pathophysiology of neurogenic orthostatic hypotension resulted in the discovery of a new therapeutic pathway targeted by NRI.
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Affiliation(s)
- Naome Mwesigwa
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN (N.M., C.A.S.)
| | - Cyndya A Shibao
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN (N.M., C.A.S.)
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4
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Shibao CA, Harrison DG, Biaggioni I. David Herlie Robertson, MD. Hypertension 2024; 81:e44-e46. [PMID: 38630798 DOI: 10.1161/hypertensionaha.124.22755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Affiliation(s)
- Cyndya A Shibao
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - David G Harrison
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Italo Biaggioni
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
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5
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Biaggioni I, Arnold AC, Black B, Diedrich A, Furlan R, Gamboa A, Garland E, Jacob G, Jordan J, Okamoto LE, Raj SR, Sato K, Shannon J, Tank J, Peltier A, Shibao CA. In memoriam: a celebration of the autonomic contributions of David Robertson (1947-2024). Clin Auton Res 2024; 34:5-7. [PMID: 38436914 DOI: 10.1007/s10286-024-01025-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 01/25/2024] [Indexed: 03/05/2024]
Affiliation(s)
- Italo Biaggioni
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, 37232, USA.
| | - Amy C Arnold
- Department of Neural and Behavioral Sciences, Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Bonnie Black
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, 37232, USA
| | - Andre Diedrich
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, 37232, USA
| | - Raffaello Furlan
- Internal Medicine and Syncope Unit, Humanitas Research Hospital, Humanitas University, Rozzano, Italy
| | - Alfredo Gamboa
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, 37232, USA
| | - Emily Garland
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, 37232, USA
| | - Giris Jacob
- Deparment of Internal Medicine, Recanati Autonomic Dysfunction Center, Sourasky Medical Center and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jens Jordan
- Institute of Aerospace Medicine, German Aerospace Center and Medical Faculty, University of Cologne, Cologne, Germany
| | - Luis E Okamoto
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, 37232, USA
| | - Satish R Raj
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, 37232, USA
- Department of Cardiac Sciences, Cumming School of Medicine, Libin Cardiovascular Institute, University of Calgary, Calgary, Canada
| | - Kyoko Sato
- Adachi Medical Center, Tokyo Women's Medical University, Tokyo, Japan
| | | | - Jens Tank
- Institute of Aerospace Medicine, German Aerospace Center and Medical Faculty, University of Cologne, Cologne, Germany
| | - Amanda Peltier
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, 37232, USA
| | - Cyndya A Shibao
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, 37232, USA
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Chen B, Yang W, Luo Y, Tan EK, Wang Q. Non-pharmacological and drug treatment of autonomic dysfunction in multiple system atrophy: current status and future directions. J Neurol 2023; 270:5251-5273. [PMID: 37477834 DOI: 10.1007/s00415-023-11876-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 07/11/2023] [Accepted: 07/11/2023] [Indexed: 07/22/2023]
Abstract
Multiple system atrophy (MSA) is a sporadic, fatal, and rapidly progressive neurodegenerative disease of unknown etiology that is clinically characterized by autonomic failure, parkinsonism, cerebellar ataxia, and pyramidal signs in any combination. Early onset and extensive autonomic dysfunction, including cardiovascular dysfunction characterized by orthostatic hypotension (OH) and supine hypertension, urinary dysfunction characterized by overactive bladder and incomplete bladder emptying, sexual dysfunction characterized by sexual desire deficiency and erectile dysfunction, and gastrointestinal dysfunction characterized by delayed gastric emptying and constipation, are the main features of MSA. Autonomic dysfunction greatly reduces quality of life and increases mortality. Therefore, early diagnosis and intervention are urgently needed to benefit MSA patients. In this review, we aim to discuss the systematic treatment of autonomic dysfunction in MSA, and focus on the current methods, starting from non-pharmacological methods, such as patient education, psychotherapy, diet change, surgery, and neuromodulation, to various drug treatments targeting autonomic nerve and its projection fibers. In addition, we also draw attention to the interactions among various treatments, and introduce novel methods proposed in recent years, such as gene therapy, stem cell therapy, and neural prosthesis implantation. Furthermore, we elaborate on the specific targets and mechanisms of action of various drugs. We would like to call for large-scale research to determine the efficacy of these methods in the future. Finally, we point out that studies on the pathogenesis of MSA and pathophysiological mechanisms of various autonomic dysfunction would also contribute to the development of new promising treatments and concepts.
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Affiliation(s)
- BaoLing Chen
- Department of Neurology, Zhujiang Hospital, Southern Medical University, Gongye Road 253, Guangzhou, 510282, Guangdong, People's Republic of China
| | - Wanlin Yang
- Department of Neurology, Zhujiang Hospital, Southern Medical University, Gongye Road 253, Guangzhou, 510282, Guangdong, People's Republic of China
| | - Yuqi Luo
- Department of Neurology, Zhujiang Hospital, Southern Medical University, Gongye Road 253, Guangzhou, 510282, Guangdong, People's Republic of China
| | - Eng-King Tan
- Department of Neurology, National Neuroscience Institute, Singapore General Hospital, Singapore, Singapore.
- Duke-NUS Medical School, Singapore, Singapore.
| | - Qing Wang
- Department of Neurology, Zhujiang Hospital, Southern Medical University, Gongye Road 253, Guangzhou, 510282, Guangdong, People's Republic of China.
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7
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Okamoto LE, Celedonio JE, Smith EC, Paranjape SY, Black BK, Wahba A, Park JW, Shibao CA, Diedrich A, Biaggioni I. Continuous Positive Airway Pressure for the Treatment of Supine Hypertension and Orthostatic Hypotension in Autonomic Failure. Hypertension 2023; 80:650-658. [PMID: 36601916 PMCID: PMC10128890 DOI: 10.1161/hypertensionaha.122.20081] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 12/14/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND Supine hypertension affects most patients with orthostatic hypotension (OH) due to autonomic failure, but it is often untreated for fear of worsening OH. We hypothesized that increasing intrathoracic pressure with continuous positive airway pressure (CPAP) had a Valsalva-like blood-pressure-lowering effect that could be used to treat nocturnal supine hypertension in these patients, while reducing nocturnal pressure diuresis and improving daytime OH. METHODS In Protocol 1, we determined the acute hemodynamic effects of increasing levels of CPAP (0, 4, 8, 12, and 16 cm H2O, 3 minutes each) in 26 patients with autonomic failure and supine hypertension studied while awake and supine. In Protocol 2 (n=11), we compared the effects of overnight therapy with CPAP (8-12 cm H2O for 8 hours) versus placebo on nocturnal supine hypertension, nocturnal diuresis and daytime OH in a 2-night crossover study. RESULTS In Protocol 1, acute CPAP (4-16 cm H2O) decreased systolic blood pressure in a dose-dependent manner (maximal drop 22±4 mmHg with CPAP 16) due to reductions in stroke volume (-16+3%) and cardiac output (-14±3%). Systemic vascular resistance and heart rate remained unchanged. In Protocol 2, overnight CPAP lowered nighttime systolic blood pressure (maximal change -23±5 versus placebo -1±7 mmHg; P=0.023) and was associated with lower nighttime diuresis (609±84 versus placebo 1004±160 mL; P=0.004) and improved morning orthostatic tolerance (AUC upright SBP 642±121 versus placebo 410±109 mmHg*min; P=0.014). CONCLUSIONS CPAP is a novel nonpharmacologic approach to treat the supine hypertension of autonomic failure while improving nocturia and daytime OH. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT03312556.
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Affiliation(s)
- Luis E. Okamoto
- Vanderbilt Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jorge E. Celedonio
- Vanderbilt Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Emily C. Smith
- Vanderbilt Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sachin Y. Paranjape
- Vanderbilt Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Bonnie K. Black
- Vanderbilt Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Amr Wahba
- Vanderbilt Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jin-Woo Park
- Vanderbilt Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Cyndya A. Shibao
- Vanderbilt Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - André Diedrich
- Vanderbilt Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Biomedical Engineering, Vanderbilt University, Nashville, Tennessee, USA
| | - Italo Biaggioni
- Vanderbilt Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Pharmacology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Jung YJ, Kim A, Okamoto LE, Hong WH. Effects of Atomoxetine for the Treatment of Neurogenic Orthostatic Hypotension in Patients With Alpha-synucleinopathies: A Systematic Review of Randomized Controlled Trials and a Focus-Group Discussion. J Clin Neurol 2023; 19:165-173. [PMID: 36647224 PMCID: PMC9982187 DOI: 10.3988/jcn.2022.0018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Revised: 08/03/2022] [Accepted: 08/03/2022] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND AND PURPOSE Neurogenic orthostatic hypotension (nOH) is one of the most important nonmotor symptoms in patients with α-synucleinopathies. Atomoxetine is a selective norepinephrine transporter blocker that is a treatment option for nOH. This systematic review and expert focus-group study was designed to obtain evidence from published data and clinical experiences of Korean movement-disorder specialists about the efficacy and safety of atomoxetine for the pharmacological treatment of nOH in patients with α-synucleinopathies. METHODS The study comprised a systematic review and a focus-group discussion with clinicians. For the systematic review, multiple comprehensive databases including MEDLINE, Embase, Cochrane Library, CINAHL, PsycInfo, and KoreaMed were searched to retrieve articles that assessed the outcomes of atomoxetine therapy. A focus-group discussion was additionally performed to solicit opinions from experts with experience in managing nOH. RESULTS The literature review process yielded only four randomized controlled trials on atomoxetine matching the inclusion criteria. Atomoxetine effectively increased systolic blood pressure and improved OH-related symptoms as monotherapy or in combination with other drugs. Its effects were pronounced in cases with central autonomic failure, including multiple-system atrophy (MSA). Atomoxetine might be a safe monotherapy regarding the risk of supine hypertension. CONCLUSIONS Atomoxetine is an effective and safe option for short-term nOH management, which could be more evident in patients with central autonomic dysfunction such as MSA. However, there is a paucity of evidence in the literature, and data from the focus-group discussion were inadequate, and so further investigation is warranted.
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Affiliation(s)
- Yu Jin Jung
- Department of Neurology, Daejeon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Aryun Kim
- Department of Neurology, Chungbuk National University Hospital, Cheongju, Korea
| | - Luis E. Okamoto
- Department of Medicine, Division of Clinical Pharmacology and the Autonomic Dysfunction Center, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Woi-Hyun Hong
- College of Medicine and Medical Research Information Center (MedRIC), Chungbuk National University, Cheongju, Korea.
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Fedorowski A, Ricci F, Hamrefors V, Sandau KE, Chung TH, Muldowney JAS, Gopinathannair R, Olshansky B. Orthostatic Hypotension: Management of a Complex, But Common, Medical Problem. Circ Arrhythm Electrophysiol 2022; 15:e010573. [PMID: 35212554 PMCID: PMC9049902 DOI: 10.1161/circep.121.010573] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Orthostatic hypotension (OH), a common, often overlooked, disorder with many causes, is associated with debilitating symptoms, falls, syncope, cognitive impairment, and risk of death. Chronic OH, a cardinal sign of autonomic dysfunction, increases with advancing age and is commonly associated with neurodegenerative and autoimmune diseases, diabetes, hypertension, heart failure, and kidney failure. Management typically involves a multidisciplinary, patient-centered, approach to arrive at an appropriate underlying diagnosis that is causing OH, treating accompanying conditions, and providing individually tailored pharmacological and nonpharmacological treatment. We propose a novel streamlined pathophysiological classification of OH; review the relationship between the cardiovascular disease continuum and OH; discuss OH-mediated end-organ damage; provide diagnostic and therapeutic algorithms to guide clinical decision making and patient care; identify current gaps in knowledge and try to define future research directions. Using a case-based learning approach, specific clinical scenarios are presented highlighting various presentations of OH to provide a practical guide to evaluate and manage patients who have OH.
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Affiliation(s)
- Artur Fedorowski
- Dept of Clinical Sciences, Lund University, Malmö
- Dept of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Fabrizio Ricci
- Dept of Clinical Sciences, Lund University, Malmö
- Dept of Neuroscience, Imaging & Clinical Sciences, “G.d’Annunzio” University, Chieti-Pescara
- Casa di Cura Villa Serena, Città Sant’Angelo, Italy
| | - Viktor Hamrefors
- Dept of Clinical Sciences, Lund University, Malmö
- Dept of Internal Medicine, Skåne University Hospital, Malmö, Sweden
| | | | - Tae Hwan Chung
- Dept of Physical Medicine & Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD
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10
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New approaches to treatments for sleep, pain and autonomic failure in Parkinson's disease - Pharmacological therapies. Neuropharmacology 2022; 208:108959. [PMID: 35051446 DOI: 10.1016/j.neuropharm.2022.108959] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Revised: 01/08/2022] [Accepted: 01/13/2022] [Indexed: 01/07/2023]
Abstract
Non-motor symptoms (NMSs) are highly prevalent throughout the course of Parkinson's disease (PD). Pain, autonomic dysfunction and sleep disturbances remain at the forefront of the most common NMSs; their treatment is challenging and their effect on the quality of life of both patients and caregivers detrimental. Yet, the landscape of clinical trials in PD is still dominated by therapeutic strategies seeking to ameliorate motor symptoms; subsequently, effective strategies to successfully treat NMSs remain a huge unmet need. Wider awareness among industry and researchers is thus essential to give rise to development and delivery of high-quality, large-scale clinical trials in enriched populations of patients with PD-related pain, autonomic dysfunction and sleep. In this review, we discuss recent developments in the field of pharmacological treatment strategies designed or re-purposed to target three key NMSs: pain, autonomic dysfunction and sleep disturbances. We focus on emerging evidence from recent clinical trials and outline some exciting and intriguing findings that call for further investigations.
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Okamoto LE, Celedonio JE, Smith EC, Gamboa A, Shibao CA, Diedrich A, Paranjape SY, Black BK, Muldowney JAS, Peltier AC, Habermann R, Crandall CG, Biaggioni I. Local Passive Heat for the Treatment of Hypertension in Autonomic Failure. J Am Heart Assoc 2021; 10:e018979. [PMID: 33739123 PMCID: PMC8174330 DOI: 10.1161/jaha.120.018979] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Background Supine hypertension affects a majority of patients with autonomic failure; it is associated with end‐organ damage and can worsen daytime orthostatic hypotension by inducing pressure diuresis and volume loss during the night. Because sympathetic activation prevents blood pressure (BP) from falling in healthy subjects exposed to heat, we hypothesized that passive heat had a BP‐lowering effect in patients with autonomic failure and could be used to treat their supine hypertension. Methods and Results In Protocol 1 (n=22), the acute effects of local heat (40–42°C applied with a heating pad placed over the abdomen for 2 hours) versus sham control were assessed in a randomized crossover fashion. Heat acutely decreased systolic BP by −19±4 mm Hg (versus 3±4 with sham, P<0.001) owing to decreases in stroke volume (−18±5% versus −4±4%, P=0.013 ) and cardiac output (−15±5% versus −2±4%, P=0.013). In Protocol 2 (proof‐of‐concept overnight study; n=12), we compared the effects of local heat (38°C applied with a water‐perfused heating pad placed under the torso from 10 pm to 6 am) versus placebo pill. Heat decreased nighttime systolic BP (maximal change −28±6 versus −2±6 mm Hg, P<0.001). BP returned to baseline by 8 am. The nocturnal systolic BP decrease correlated with a decrease in urinary volume (r=0.57, P=0.072) and an improvement in the morning upright systolic BP (r=−0.76, P=0.007). Conclusions Local heat therapy effectively lowered overnight BP in patients with autonomic failure and supine hypertension and offers a novel approach to treat this condition. Future studies are needed to assess the long‐term safety and efficacy in improving nighttime fluid loss and daytime orthostatic hypotension. Registration URL: https://www.clinicaltrials.gov; Unique identifiers: NCT02417415 and NCT03042988.
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Affiliation(s)
- Luis E Okamoto
- Vanderbilt Autonomic Dysfunction Center Vanderbilt University Medical Center Nashville TN.,Division of Clinical Pharmacology Vanderbilt University Medical Center Nashville TN.,Department of Medicine Vanderbilt University Medical Center Nashville TN
| | - Jorge E Celedonio
- Vanderbilt Autonomic Dysfunction Center Vanderbilt University Medical Center Nashville TN.,Division of Clinical Pharmacology Vanderbilt University Medical Center Nashville TN.,Department of Medicine Vanderbilt University Medical Center Nashville TN
| | - Emily C Smith
- Vanderbilt Autonomic Dysfunction Center Vanderbilt University Medical Center Nashville TN.,Division of Clinical Pharmacology Vanderbilt University Medical Center Nashville TN.,Department of Medicine Vanderbilt University Medical Center Nashville TN
| | - Alfredo Gamboa
- Vanderbilt Autonomic Dysfunction Center Vanderbilt University Medical Center Nashville TN.,Division of Clinical Pharmacology Vanderbilt University Medical Center Nashville TN.,Department of Medicine Vanderbilt University Medical Center Nashville TN
| | - Cyndya A Shibao
- Vanderbilt Autonomic Dysfunction Center Vanderbilt University Medical Center Nashville TN.,Division of Clinical Pharmacology Vanderbilt University Medical Center Nashville TN.,Department of Medicine Vanderbilt University Medical Center Nashville TN
| | - André Diedrich
- Vanderbilt Autonomic Dysfunction Center Vanderbilt University Medical Center Nashville TN.,Division of Clinical Pharmacology Vanderbilt University Medical Center Nashville TN.,Department of Medicine Vanderbilt University Medical Center Nashville TN.,Department of Biomedical Engineering Vanderbilt University Medical Center Nashville TN
| | - Sachin Y Paranjape
- Vanderbilt Autonomic Dysfunction Center Vanderbilt University Medical Center Nashville TN.,Division of Clinical Pharmacology Vanderbilt University Medical Center Nashville TN.,Department of Medicine Vanderbilt University Medical Center Nashville TN
| | - Bonnie K Black
- Vanderbilt Autonomic Dysfunction Center Vanderbilt University Medical Center Nashville TN.,Division of Clinical Pharmacology Vanderbilt University Medical Center Nashville TN.,Department of Medicine Vanderbilt University Medical Center Nashville TN
| | - James A S Muldowney
- Vanderbilt Autonomic Dysfunction Center Vanderbilt University Medical Center Nashville TN.,Division of Clinical Pharmacology Vanderbilt University Medical Center Nashville TN.,Division of Cardiology Vanderbilt University Medical Center Nashville TN.,Department of Medicine Vanderbilt University Medical Center Nashville TN
| | - Amanda C Peltier
- Vanderbilt Autonomic Dysfunction Center Vanderbilt University Medical Center Nashville TN.,Division of Clinical Pharmacology Vanderbilt University Medical Center Nashville TN.,Department of Neurology Vanderbilt University Medical Center Nashville TN
| | - Ralf Habermann
- Vanderbilt Autonomic Dysfunction Center Vanderbilt University Medical Center Nashville TN.,Division of Clinical Pharmacology Vanderbilt University Medical Center Nashville TN.,Division of Geriatrics Vanderbilt University Medical Center Nashville TN.,Department of Medicine Vanderbilt University Medical Center Nashville TN
| | - Craig G Crandall
- Institute for Exercise and Environmental Medicine Texas Health Presbyterian Hospital and UT Southwestern Medical Center Dallas TX
| | - Italo Biaggioni
- Vanderbilt Autonomic Dysfunction Center Vanderbilt University Medical Center Nashville TN.,Division of Clinical Pharmacology Vanderbilt University Medical Center Nashville TN.,Department of Medicine Vanderbilt University Medical Center Nashville TN.,Department of Pharmacology Vanderbilt University Medical Center Nashville TN
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Abstract
PURPOSE OF REVIEW This article reviews the management of orthostatic hypotension with emphasis on neurogenic orthostatic hypotension. RECENT FINDINGS Establishing whether the cause of orthostatic hypotension is a pathologic lesion in sympathetic neurons (ie, neurogenic orthostatic hypotension) or secondary to other medical causes (ie, non-neurogenic orthostatic hypotension) can be achieved by measuring blood pressure and heart rate at the bedside. Whereas fludrocortisone has been extensively used as first-line treatment in the past, it is associated with adverse events including renal and cardiac failure and increased risk of all-cause hospitalization. Distinguishing whether neurogenic orthostatic hypotension is caused by central or peripheral dysfunction has therapeutic implications. Patients with peripheral sympathetic denervation respond better to norepinephrine agonists/precursors such as droxidopa, whereas patients with central autonomic dysfunction respond better to norepinephrine reuptake inhibitors. SUMMARY Management of orthostatic hypotension is aimed at improving quality of life and reducing symptoms rather than at normalizing blood pressure. Nonpharmacologic measures are the key to success. Pharmacologic options include volume expansion with fludrocortisone and sympathetic enhancement with midodrine, droxidopa, and norepinephrine reuptake inhibitors. Neurogenic supine hypertension complicates management of orthostatic hypotension and is primarily ameliorated by avoiding the supine position and sleeping with the head of the bed elevated.
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13
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Fahey OG, Piccolo JK, Bergsbaken JJ, N Dow-Hillgartner E. Hypertension and QT interval prolongation associated with targeted systemic cancer therapies. J Oncol Pharm Pract 2020; 26:1987-1996. [DOI: 10.1177/1078155220958462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective To summarize the proposed mechanisms behind hypertension and QT interval prolongation associated with use of targeted systemic cancer therapies and provide recommendations for monitoring or managing these toxicities. Summary The cardiotoxic effects of targeted systemic cancer therapies represents a new paradigm of cancer treatment associated cardiovascular adverse events. National guidelines regarding optimal monitoring and management strategies for hypertension and QT interval prolongation associated with use of these therapies are lacking. While the pathophysiological drivers of hypertension due to targeted systemic cancer therapies differ by class of targeted therapy, general management strategies do not. Routine blood pressure monitoring throughout the duration of therapy is recommended for all agents. Patients who experience hypertension often can be treated with the addition or modification of antihypertensive therapies. Uncontrolled hypertension despite optimal medical management may require dose modifications or discontinuation of the targeted systemic cancer therapy. Electrocardiogram monitoring is recommended for patients who receive targeted therapies that may prolong the QT interval. Minimizing or managing drug interactions with other QT prolonging medications is recommended in addition to ensuring adequate electrolyte supplementation. Dose modifications or discontinuation of the targeted systemic therapy may be necessary for patients who experience QT interval prolongation. Conclusions Appropriate cardiovascular monitoring and timely management of treatment-emergent toxicities can optimize therapy for patients receiving targeted systemic cancer therapies associated with a risk of drug-induced hypertension or QT interval prolongation.
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Affiliation(s)
- Olivia G Fahey
- Department of Pharmacy, University of Kansas Cancer Center, Westwood, KS, USA
| | - Jennifer K Piccolo
- Department of Pharmacy, William S. Middleton Memorial Veterans Hospital, Madison, WI, USA
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Palma JA, Kaufmann H. Clinical Trials for Neurogenic Orthostatic Hypotension: A Comprehensive Review of Endpoints, Pitfalls, and Challenges. Semin Neurol 2020; 40:523-539. [PMID: 32906173 DOI: 10.1055/s-0040-1713846] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Neurogenic orthostatic hypotension (nOH) is among the most debilitating nonmotor features of patients with Parkinson's disease (PD) and other synucleinopathies. Patients with PD and nOH generate more hospitalizations, make more emergency room visits, create more telephone calls/mails to doctors, and have earlier mortality than those with PD but without nOH. Overall, the health-related cost in patients with PD and OH is 2.5-fold higher compared with patients with PD without OH. Hence, developing effective therapies for nOH should be a research priority. In the last few decades, improved understanding of the pathophysiology of nOH has led to the identification of therapeutic targets and the development and approval of two drugs, midodrine and droxidopa. More effective and safer therapies, however, are still needed, particularly agents that could selectively increase blood pressure only in the standing position because supine hypertension is the main limitation of available drugs. Here we review the design and conduct of nOH clinical trials in patients with PD and other synucleinopathies, summarize the results of the most recently completed and ongoing trials, and discuss challenges, bottlenecks, and potential remedies.
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Affiliation(s)
- Jose-Alberto Palma
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, New York, New York
| | - Horacio Kaufmann
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, New York, New York
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15
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Park JW, Okamoto LE, Shibao CA, Biaggioni I. Pharmacologic treatment of orthostatic hypotension. Auton Neurosci 2020; 229:102721. [PMID: 32979782 DOI: 10.1016/j.autneu.2020.102721] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 08/18/2020] [Accepted: 08/23/2020] [Indexed: 12/20/2022]
Abstract
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.
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Affiliation(s)
- Jin-Woo Park
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States of America; Institute for Inflammation Control, Korea University, Seoul, Republic of Korea
| | - Luis E Okamoto
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Cyndya A Shibao
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Italo Biaggioni
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States of America; Department of Pharmacology, Vanderbilt University Medical Center, Nashville, TN, United States of America.
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Olshansky B, Muldowney J. Cardiovascular Safety Considerations in the Treatment of Neurogenic Orthostatic Hypotension. Am J Cardiol 2020; 125:1582-1593. [PMID: 32204870 DOI: 10.1016/j.amjcard.2020.01.037] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 01/18/2020] [Accepted: 01/22/2020] [Indexed: 12/17/2022]
Abstract
Neurogenic orthostatic hypotension (nOH), a drop in blood pressure upon standing resulting from autonomic malfunction, may cause debilitating symptoms that can affect independence in daily activities and quality-of-life. nOH may also be associated with cardiovascular comorbidities (e.g., supine hypertension, heart failure, diabetes, and arrhythmias), making treatment decisions complicated and requiring management that should be based on a patient's cardiovascular profile. Additionally, drugs used to treat the cardiovascular disorders (e.g., vasodilators, β-blockers) can exacerbate nOH and concomitant symptoms. When orthostatic symptoms are severe and not effectively managed with nonpharmacologic strategies (e.g., water ingestion, abdominal compression), droxidopa or midodrine may be effective. Droxidopa may be less likely than midodrine to exacerbate supine hypertension, based on conclusions of a limited meta-analysis. In conclusion, treating nOH in patients with cardiovascular conditions requires a balance between symptom relief and minimizing adverse outcomes.
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17
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Quarracino C, Otero-Losada M, Capani F, Pérez-Lloret S. State-of-the-art pharmacotherapy for autonomic dysfunction in Parkinson’s disease. Expert Opin Pharmacother 2020; 21:445-457. [DOI: 10.1080/14656566.2020.1713097] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Cecilia Quarracino
- Institute of Cardiological Research, University of Buenos Aires, National Research Council, ININCA, UBA, CONICET, Buenos Aires, Argentina
| | - Matilde Otero-Losada
- Institute of Cardiological Research, University of Buenos Aires, National Research Council, ININCA, UBA, CONICET, Buenos Aires, Argentina
| | - Francisco Capani
- Institute of Cardiological Research, University of Buenos Aires, National Research Council, ININCA, UBA, CONICET, Buenos Aires, Argentina
| | - Santiago Pérez-Lloret
- Institute of Cardiological Research, University of Buenos Aires, National Research Council, ININCA, UBA, CONICET, Buenos Aires, Argentina
- Department of Physiology, School of Medicine, University of Buenos Aires (UBA), Buenos Aires, Argentina
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18
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Byun JI, Kim DY, Moon J, Shin HR, Sunwoo JS, Lee WJ, Lee HS, Park KI, Lee ST, Jung KH, Jung KY, Kim M, Lee SK, Chu K. Efficacy of atomoxetine versus midodrine for neurogenic orthostatic hypotension. Ann Clin Transl Neurol 2019; 7:112-120. [PMID: 31856425 PMCID: PMC6952305 DOI: 10.1002/acn3.50968] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Revised: 11/21/2019] [Accepted: 11/22/2019] [Indexed: 11/11/2022] Open
Abstract
Objective The efficacy and safety of 1‐month atomoxetine and midodrine therapies were compared. Three‐month atomoxetine and combination therapies were investigated for additional benefits. Methods This prospective open‐label randomized trial included 50 patients with symptomatic neurogenic orthostatic hypotension (nOH). The patients received either atomoxetine 18 mg daily or midodrine 5 mg twice daily and were evaluated 1 and 3 months later. Those who still met the criteria for nOH at 1 month received both midodrine and atomoxetine for an additional 2 months, and if not, they continued their initial medication. The primary outcome was an improvement in orthostatic blood pressure (BP) drop (maximum BP change from supine to 3 min after standing) at 1 month. The secondary endpoints were symptom scores, percentage of patients with nOH at 1 and 3 months. Results Patients with midodrine or atomoxetine treatment showed comparative improvement in the orthostatic BP drop, and overall only 26.2% of the patients had nOH at 1 month, which was similar between the treatment groups. Only atomoxetine resulted in significant symptomatic improvements at 1 month. For those without nOH at 1 month, there was additional symptomatic improvement at 3 months with their initial medication. For those with nOH at 1 month, the combination treatment resulted in no additional improvement. Mild‐to‐moderate adverse events were reported by 11.6% of the patients. Interpretation One‐month atomoxetine treatment was effective and safe in nOH patients. Atomoxetine improved orthostatic BP changes as much as midodrine and was better in terms of ameliorating nOH symptoms.
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Affiliation(s)
- Jung-Ick Byun
- Laboratory for Neurotherapeutics, Department of Neurology, Comprehensive Epilepsy Center, Center for Medical Innovations, Biomedical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea.,Department of Neurology, Kyung Hee University Hospital at Gangdong, Seoul, Republic of Korea.,Program in Neuroscience, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Do-Yong Kim
- Laboratory for Neurotherapeutics, Department of Neurology, Comprehensive Epilepsy Center, Center for Medical Innovations, Biomedical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jangsup Moon
- Laboratory for Neurotherapeutics, Department of Neurology, Comprehensive Epilepsy Center, Center for Medical Innovations, Biomedical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea.,Program in Neuroscience, Seoul National University College of Medicine, Seoul, Republic of Korea.,Rare Disease Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - Hye-Rim Shin
- Laboratory for Neurotherapeutics, Department of Neurology, Comprehensive Epilepsy Center, Center for Medical Innovations, Biomedical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea.,Program in Neuroscience, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jun-Sang Sunwoo
- Laboratory for Neurotherapeutics, Department of Neurology, Comprehensive Epilepsy Center, Center for Medical Innovations, Biomedical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea.,Department of Neurosurgery, Seoul National University Hospital, Seoul, Republic of Korea
| | - Woo-Jin Lee
- Laboratory for Neurotherapeutics, Department of Neurology, Comprehensive Epilepsy Center, Center for Medical Innovations, Biomedical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea.,Program in Neuroscience, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Han-Sang Lee
- Laboratory for Neurotherapeutics, Department of Neurology, Comprehensive Epilepsy Center, Center for Medical Innovations, Biomedical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea.,Program in Neuroscience, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Kyung-Il Park
- Department of Neurology, Seoul National University Hospital Healthcare System Gangnam Center, Seoul, Republic of Korea
| | - Soon-Tae Lee
- Laboratory for Neurotherapeutics, Department of Neurology, Comprehensive Epilepsy Center, Center for Medical Innovations, Biomedical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea.,Program in Neuroscience, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Keun-Hwa Jung
- Laboratory for Neurotherapeutics, Department of Neurology, Comprehensive Epilepsy Center, Center for Medical Innovations, Biomedical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea.,Program in Neuroscience, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Ki-Young Jung
- Laboratory for Neurotherapeutics, Department of Neurology, Comprehensive Epilepsy Center, Center for Medical Innovations, Biomedical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea.,Program in Neuroscience, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Manho Kim
- Laboratory for Neurotherapeutics, Department of Neurology, Comprehensive Epilepsy Center, Center for Medical Innovations, Biomedical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea.,Program in Neuroscience, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Sang Kun Lee
- Laboratory for Neurotherapeutics, Department of Neurology, Comprehensive Epilepsy Center, Center for Medical Innovations, Biomedical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea.,Program in Neuroscience, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Kon Chu
- Laboratory for Neurotherapeutics, Department of Neurology, Comprehensive Epilepsy Center, Center for Medical Innovations, Biomedical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea.,Program in Neuroscience, Seoul National University College of Medicine, Seoul, Republic of Korea
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19
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Okamoto LE, Shibao CA, Gamboa A, Diedrich A, Raj SR, Black BK, Robertson D, Biaggioni I. Synergistic Pressor Effect of Atomoxetine and Pyridostigmine in Patients With Neurogenic Orthostatic Hypotension. Hypertension 2019; 73:235-241. [PMID: 30571543 DOI: 10.1161/hypertensionaha.118.11790] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Patients with autonomic failure are characterized by disabling orthostatic hypotension because of impaired sympathetic activity, but even severely affected patients have residual sympathetic tone which can be harnessed for their treatment. For example, norepinephrine transporter blockade with atomoxetine raises blood pressure (BP) in autonomic failure patients by increasing synaptic norepinephrine concentrations; acetylcholinesterase inhibition with pyridostigmine increases BP by facilitating ganglionic cholinergic neurotransmission to increase sympathetic outflow. We tested the hypothesis that pyridostigmine will potentiate the pressor effect of atomoxetine and improve orthostatic tolerance and symptoms in patients with severe autonomic failure. Twelve patients received a single oral dose of either placebo, pyridostigmine 60 mg, atomoxetine 18 mg or the combination on separate days in a single blind, crossover study. BP was assessed seated and standing before and 1-hour postdrug. In these severely affected patients, neither pyridostigmine nor atomoxetine improved BP or orthostatic tolerance compared with placebo. The combination, however, significantly increased seated BP in a synergistic manner (133±9/80±4 versus 107±6/66±4 mm Hg for placebo, 105±5/67±3 mm Hg for atomoxetine, and 99±6/64±4 mm Hg for pyridostigmine; P<0.001); the maximal increase in seated BP with the combination was 33±8/18±3 mm Hg at 60 minutes postdrug. Only the combination showed a significant improvement of orthostatic tolerance and symptoms. In conclusion, the combination pyridostigmine and atomoxetine had a synergistic effect on seated BP which was associated with improvement in orthostatic tolerance and symptoms. This pharmacological approach could be useful in patients with severe autonomic failure but further safety and long-term efficacy studies are needed.
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Affiliation(s)
- Luis E Okamoto
- From the Vanderbilt Autonomic Dysfunction Center (L.E.O., C.A.S., A.G. A.D., S.R.R., B.K.B., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN.,Division of Clinical Pharmacology (L.E.O., C.A.S., A.G., A.D., S.R.R., B.K.B., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN.,Department of Medicine (L.E.O., C.A.S., A.G., A.D., S.R.R., B.K.B., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN
| | - Cyndya A Shibao
- From the Vanderbilt Autonomic Dysfunction Center (L.E.O., C.A.S., A.G. A.D., S.R.R., B.K.B., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN.,Division of Clinical Pharmacology (L.E.O., C.A.S., A.G., A.D., S.R.R., B.K.B., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN.,Department of Medicine (L.E.O., C.A.S., A.G., A.D., S.R.R., B.K.B., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN
| | - Alfredo Gamboa
- From the Vanderbilt Autonomic Dysfunction Center (L.E.O., C.A.S., A.G. A.D., S.R.R., B.K.B., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN.,Division of Clinical Pharmacology (L.E.O., C.A.S., A.G., A.D., S.R.R., B.K.B., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN.,Department of Medicine (L.E.O., C.A.S., A.G., A.D., S.R.R., B.K.B., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN
| | - André Diedrich
- From the Vanderbilt Autonomic Dysfunction Center (L.E.O., C.A.S., A.G. A.D., S.R.R., B.K.B., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN.,Division of Clinical Pharmacology (L.E.O., C.A.S., A.G., A.D., S.R.R., B.K.B., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN.,Department of Medicine (L.E.O., C.A.S., A.G., A.D., S.R.R., B.K.B., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN.,Department of Biomedical Engineering (A.D.), Vanderbilt University School of Medicine, Nashville, TN
| | - Satish R Raj
- From the Vanderbilt Autonomic Dysfunction Center (L.E.O., C.A.S., A.G. A.D., S.R.R., B.K.B., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN.,Division of Clinical Pharmacology (L.E.O., C.A.S., A.G., A.D., S.R.R., B.K.B., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN.,Department of Medicine (L.E.O., C.A.S., A.G., A.D., S.R.R., B.K.B., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN.,Department of Pharmacology (S.R.R., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN.,Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, University of Calgary, Canada (S.R.R.)
| | - Bonnie K Black
- From the Vanderbilt Autonomic Dysfunction Center (L.E.O., C.A.S., A.G. A.D., S.R.R., B.K.B., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN.,Division of Clinical Pharmacology (L.E.O., C.A.S., A.G., A.D., S.R.R., B.K.B., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN.,Department of Medicine (L.E.O., C.A.S., A.G., A.D., S.R.R., B.K.B., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN
| | - David Robertson
- From the Vanderbilt Autonomic Dysfunction Center (L.E.O., C.A.S., A.G. A.D., S.R.R., B.K.B., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN.,Division of Clinical Pharmacology (L.E.O., C.A.S., A.G., A.D., S.R.R., B.K.B., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN.,Department of Medicine (L.E.O., C.A.S., A.G., A.D., S.R.R., B.K.B., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN.,Department of Pharmacology (S.R.R., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN.,Department of Neurology (D.R.), Vanderbilt University School of Medicine, Nashville, TN
| | - Italo Biaggioni
- From the Vanderbilt Autonomic Dysfunction Center (L.E.O., C.A.S., A.G. A.D., S.R.R., B.K.B., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN.,Division of Clinical Pharmacology (L.E.O., C.A.S., A.G., A.D., S.R.R., B.K.B., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN.,Department of Medicine (L.E.O., C.A.S., A.G., A.D., S.R.R., B.K.B., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN.,Department of Pharmacology (S.R.R., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN
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Abstract
Orthostatic hypotension (OH) is a sustained fall in blood pressure on standing that can cause symptoms of organ hypoperfusion. OH is associated with increased morbidity and mortality and leads to a significant number of hospital admissions. OH can be caused by volume depletion, blood loss, cardiac pump failure, large varicose veins, medications, or defective activation of sympathetic nerves and reduced norepinephrine release upon standing. Neurogenic OH is a frequent and disabling problem in patients with synucleinopathies such as Parkinson disease, multiple system atrophy, and pure autonomic failure, and it is commonly associated with supine hypertension. Several therapeutic options are available.
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Farooq S, Chelimsky TC. Clinical neurophysiology of multiple system atrophy. HANDBOOK OF CLINICAL NEUROLOGY 2019; 161:423-428. [PMID: 31307618 DOI: 10.1016/b978-0-444-64142-7.00065-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Multiple system atrophy (MSA) is an adult-onset, rapidly progressive neurodegenerative syndrome. The diagnosis of MSA is primarily clinical. Neurophysiologic studies can provide important clues to the diagnosis of MSA and differentiate it from other neurodegenerative diseases especially when the clinical picture is unclear. This chapter reviews common and less common neurophysiological studies useful in the diagnosis of MSA.
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Affiliation(s)
- Salman Farooq
- Department of Neurology, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Thomas C Chelimsky
- Department of Neurology, Medical College of Wisconsin, Milwaukee, WI, United States.
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22
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Cheshire WP. Chemical pharmacotherapy for the treatment of orthostatic hypotension. Expert Opin Pharmacother 2018; 20:187-199. [DOI: 10.1080/14656566.2018.1543404] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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23
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Liebe T, Li M, Colic L, Munk MHJ, Sweeney-Reed CM, Woelfer M, Kretzschmar MA, Steiner J, von Düring F, Behnisch G, Schott BH, Walter M. Ketamine influences the locus coeruleus norepinephrine network, with a dependency on norepinephrine transporter genotype - a placebo controlled fMRI study. NEUROIMAGE-CLINICAL 2018; 20:715-723. [PMID: 30238915 PMCID: PMC6146384 DOI: 10.1016/j.nicl.2018.09.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 08/12/2018] [Accepted: 09/02/2018] [Indexed: 12/14/2022]
Abstract
Background Ketamine is receiving increasing attention as a rapid-onset antidepressant in patients suffering from major depressive disorder (MDD) with treatment resistance or severe suicidal ideation. Ketamine modulates several neurotransmitter systems, including norepinephrine via the norepinephrine transporter (NET), both peripherally and centrally. The locus coeruleus (LC), which has high NET concentration, has been attributed to brain networks involved in depression. Thus we investigated the effects of single-dose of racemic ketamine on the LC using resting state functional MRI. Methods Fifty-nine healthy participants (mean age 25.57 ± 4.72) were examined in a double-blind, randomized, placebo-controlled study with 7 Tesla MRI. We investigated the resting state functional connectivity (rs-fc) of the LC before and one hour after subanesthetic ketamine injection (0.5 mg/kg), as well as associations between its rs-fc and a common polymorphism in the NET gene (rs28386840). Results A significant interaction of drug and time was revealed, and post hoc testing showed decreased rs-fc between LC and the thalamus after ketamine administration compared with baseline levels, including the mediodorsal, ventral anterior, ventral lateral, ventral posterolateral and centromedian nuclei. The rs-fc reduction was more pronounced in NET rs28386840 [AA] homozygous subjects than in [T] carriers. Conclusions We demonstrated acute rs-fc changes after ketamine administration in the central node of the norepinephrine pathway. These findings may contribute to understanding the antidepressant effect of ketamine at the system level, supporting modes of action on networks subserving aberrant arousal regulation in depression. Ketamine decreased connectivity between locus coeruleus and bilateral thalamus in resting state fMRI. This reduction of rs-fc between LC and thalamus was dependent on norepinephrine transporter genotype. The central effects of ketamine involve norepinephrine and attention networks. Antidepressive effects of ketamine may involve LC attention system.
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Affiliation(s)
- Thomas Liebe
- Clinical Affective Neuroimaging Laboratory, Leipziger Str. 44, 39112 Magdeburg, Germany; Leibniz Institute for Neurobiology, Brenneckestraße 6, 39118 Magdeburg, Germany; Clinic for Neuroradiology, University of Magdeburg, Leipziger Str. 44, Magdeburg 39120, Germany; Translational Psychiatry Tübingen, University Hospital Tübingen, Calwerstraße 14, 72076 Tübingen, Germany
| | - Meng Li
- Clinical Affective Neuroimaging Laboratory, Leipziger Str. 44, 39112 Magdeburg, Germany; Department of Neurology, Otto von Guericke University of Magdeburg, Leipziger Str. 44, 39112 Magdeburg, Germany
| | - Lejla Colic
- Clinical Affective Neuroimaging Laboratory, Leipziger Str. 44, 39112 Magdeburg, Germany; Leibniz Institute for Neurobiology, Brenneckestraße 6, 39118 Magdeburg, Germany
| | - Matthias H J Munk
- Department of Psychiatry, University of Tübingen, Calwerstr. 14, 72076 Tübingen, Germany; Department of Systems Neurophysiology, Fachbereich Biologie, Technische Universität Darmstadt, Schnittspahnstraße 10, 64287 Darmstadt, Germany
| | - Catherine M Sweeney-Reed
- Neurocybernetics and Rehabilitation, Department of Neurology, University of Magdeburg, Leipziger Str. 44, Magdeburg 39120, Germany
| | - Marie Woelfer
- Clinical Affective Neuroimaging Laboratory, Leipziger Str. 44, 39112 Magdeburg, Germany; Leibniz Institute for Neurobiology, Brenneckestraße 6, 39118 Magdeburg, Germany; Department of Biomedical Engineering, New Jersey Institute of Technology, 323 Dr Martin Luther King Jr Blvd, Newark, NJ 07102, USA
| | - Moritz A Kretzschmar
- Department of Anesthesiology and Intensive Care Medicine, University of Magdeburg, Leipziger Str. 44, Magdeburg 39120, Germany
| | - Johann Steiner
- Department of Psychiatry, University of Magdeburg, Leipziger Str. 44, Magdeburg 39120, Germany
| | - Felicia von Düring
- Clinical Affective Neuroimaging Laboratory, Leipziger Str. 44, 39112 Magdeburg, Germany; Leibniz Institute for Neurobiology, Brenneckestraße 6, 39118 Magdeburg, Germany
| | - Gusalija Behnisch
- Behavioural Neuroscience, Leibniz Institute for Neurobiology, Brenneckestraße 6, 39118 Magdeburg, Germany
| | - Björn H Schott
- Behavioural Neuroscience, Leibniz Institute for Neurobiology, Brenneckestraße 6, 39118 Magdeburg, Germany; Center for Behavioral Brain Sciences, Otto-von-Guericke-Universität Magdeburg, Universitätsplatz 2, 39106 Magdeburg, Germany; Department of Psychiatry and Psychotherapy, University Medicine Göttingen, von Siebold-Str. 5, 37075 Göttingen, Germany
| | - Martin Walter
- Clinical Affective Neuroimaging Laboratory, Leipziger Str. 44, 39112 Magdeburg, Germany; Leibniz Institute for Neurobiology, Brenneckestraße 6, 39118 Magdeburg, Germany; Department of Neurology, Otto von Guericke University of Magdeburg, Leipziger Str. 44, 39112 Magdeburg, Germany; Department of Psychiatry, University of Magdeburg, Leipziger Str. 44, Magdeburg 39120, Germany; Center for Behavioral Brain Sciences, Otto-von-Guericke-Universität Magdeburg, Universitätsplatz 2, 39106 Magdeburg, Germany; Max Planck Institute for Biological Cybernetics Tübingen, Max-Planck-Ring 8-14, 72076 Tübingen, Germany; Translational Psychiatry Tübingen, University Hospital Tübingen, Calwerstraße 14, 72076 Tübingen, Germany.
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Palma JA, Kaufmann H. Treatment of autonomic dysfunction in Parkinson disease and other synucleinopathies. Mov Disord 2018; 33:372-390. [PMID: 29508455 PMCID: PMC5844369 DOI: 10.1002/mds.27344] [Citation(s) in RCA: 130] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 01/11/2018] [Accepted: 01/24/2018] [Indexed: 12/12/2022] Open
Abstract
Dysfunction of the autonomic nervous system afflicts most patients with Parkinson disease and other synucleinopathies such as dementia with Lewy bodies, multiple system atrophy, and pure autonomic failure, reducing quality of life and increasing mortality. For example, gastrointestinal dysfunction can lead to impaired drug pharmacodynamics causing a worsening in motor symptoms, and neurogenic orthostatic hypotension can cause syncope, falls, and fractures. When recognized, autonomic problems can be treated, sometimes successfully. Discontinuation of potentially causative/aggravating drugs, patient education, and nonpharmacological approaches are useful and should be tried first. Pathophysiology-based pharmacological treatments that have shown efficacy in controlled trials of patients with synucleinopathies have been approved in many countries and are key to an effective management. Here, we review the treatment of autonomic dysfunction in patients with Parkinson disease and other synucleinopathies, summarize the nonpharmacological and current pharmacological therapeutic strategies including recently approved drugs, and provide practical advice and management algorithms for clinicians, with focus on neurogenic orthostatic hypotension, supine hypertension, dysphagia, sialorrhea, gastroparesis, constipation, neurogenic overactive bladder, underactive bladder, and sexual dysfunction. © 2018 International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Jose-Alberto Palma
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, New York, New York, USA
| | - Horacio Kaufmann
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, New York, New York, USA
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Eschlböck S, Wenning G, Fanciulli A. Evidence-based treatment of neurogenic orthostatic hypotension and related symptoms. J Neural Transm (Vienna) 2017; 124:1567-1605. [PMID: 29058089 PMCID: PMC5686257 DOI: 10.1007/s00702-017-1791-y] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Accepted: 09/18/2017] [Indexed: 02/06/2023]
Abstract
Neurogenic orthostatic hypotension, postprandial hypotension and exercise-induced hypotension are common features of cardiovascular autonomic failure. Despite the serious impact on patient’s quality of life, evidence-based guidelines for non-pharmacological and pharmacological management are lacking at present. Here, we provide a systematic review of the literature on therapeutic options for neurogenic orthostatic hypotension and related symptoms with evidence-based recommendations according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE). Patient’s education and non-pharmacological measures remain essential, with strong recommendation for use of abdominal binders. Based on quality of evidence and safety issues, midodrine and droxidopa reach a strong recommendation level for pharmacological treatment of neurogenic orthostatic hypotension. In selected cases, a range of alternative agents can be considered (fludrocortisone, pyridostigmine, yohimbine, atomoxetine, fluoxetine, ergot alkaloids, ephedrine, phenylpropanolamine, octreotide, indomethacin, ibuprofen, caffeine, methylphenidate and desmopressin), though recommendation strength is weak and quality of evidence is low (atomoxetine, octreotide) or very low (fludrocortisone, pyridostigmine, yohimbine, fluoxetine, ergot alkaloids, ephedrine, phenylpropanolamine, indomethacin, ibuprofen, caffeine, methylphenidate and desmopressin). In case of severe postprandial hypotension, acarbose and octreotide are recommended (strong recommendation, moderate level of evidence). Alternatively, voglibose or caffeine, for which a weak recommendation is available, may be useful.
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Affiliation(s)
- Sabine Eschlböck
- Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Gregor Wenning
- Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Alessandra Fanciulli
- Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.
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Vernino S, Claassen D. Polypharmacy: droxidopa to treat neurogenic orthostatic hypotension in a patient with Parkinson disease and type 2 diabetes mellitus. Clin Auton Res 2017; 27:33-34. [PMID: 28674868 PMCID: PMC5524866 DOI: 10.1007/s10286-017-0435-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Accepted: 06/08/2017] [Indexed: 11/05/2022]
Affiliation(s)
- Steven Vernino
- Department of Neurology and Neurotherapeutics, UT Southwestern, Dallas, TX, USA.
| | - Daniel Claassen
- Department of Neurology, University of Southern California, Los Angeles, CA, USA
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Liebe T, Li S, Lord A, Colic L, Krause AL, Batra A, Kretzschmar MA, Sweeney-Reed CM, Behnisch G, Schott BH, Walter M. Factors Influencing the Cardiovascular Response to Subanesthetic Ketamine: A Randomized, Placebo-Controlled Trial. Int J Neuropsychopharmacol 2017; 20:909-918. [PMID: 29099972 PMCID: PMC5737852 DOI: 10.1093/ijnp/pyx055] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Accepted: 06/28/2017] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND The increasing use of ketamine as a potential rapid-onset antidepressant necessitates a better understanding of its effects on blood pressure and heart rate, well-known side effects at higher doses. For the subanesthetic dose used for depression, potential predictors of these cardiovascular effects are important factors influencing clinical decisions. Since ketamine influences the sympathetic nervous system, we investigated the impact of autonomic nervous system-related factors on the cardiovascular response: a genetic polymorphism in the norepinephrine transporter and gender effects. METHODS Blood pressure and heart rate were monitored during and following administration of a subanesthetic dose of ketamine or placebo in 68 healthy participants (mean age 26.04 ±5.562 years) in a double-blind, randomized, controlled, parallel-design trial. The influences of baseline blood pressure/heart rate, gender, and of a polymorphism in the norepinephrine transporter gene (NET SLC6A2, rs28386840 [A-3081T]) on blood pressure and heart rate changes were investigated. To quantify changes in blood pressure and heart rate, we calculated the maximum change from baseline (ΔMAX) and the time until maximum change (TΔMAX). RESULTS Systolic and diastolic blood pressure as well as heart rate increased significantly upon ketamine administration, but without reaching hypertensive levels. During administration, the systolic blood pressure at baseline (TP0Sys) correlated negatively with the time to achieve maximal systolic blood pressure (TΔMAXSys, P<.001). Furthermore, women showed higher maximal diastolic blood pressure change (ΔMAXDia, P<.001) and reached this peak earlier than men (TΔMAXDia, P=.017) at administration. NET rs28386840 [T] carriers reached their maximal systolic blood pressure during ketamine administration significantly earlier than [A] homozygous (TΔMAXSys, P=.030). In a combined regression model, both genetic polymorphism and TP0Sys were significant predictors of TΔMAXSys (P<.0005). CONCLUSIONS Subanesthetic ketamine increased both blood pressure and heart rate without causing hypertensive events. Furthermore, we identified gender and NET rs28386840 genotype as factors that predict increased cardiovascular sequelae of ketamine administration in our young, healthy study population providing a potential basis for establishing monitoring guidelines.
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Affiliation(s)
- Thomas Liebe
- Clinical Affective Neuroimaging Laboratory, Leibniz Institute for Neurobiology, Magdeburg, Germany (Dr Liebe, Ms Colic, and Dr Krause); School of Psychology and Cognitive Science, East China Normal University, Shanghai, China (Dr Li); Department of Immunology, Queensland Institute of Medical Research, Herston, Queensland, Australia (Dr Lord); Department of Psychiatry and Psychotherapy, University Hospital Tübingen, Tübingen, Germany (Dr Batra); Department of Anesthesiology and Intensive Care Medicine (Dr Kretzschmar) and Neurocybernetics and Rehabilitation (Dr Sweeney-Reed), University Hospital, Magdeburg, Germany; Behavioural Neuroscience, Leibniz Institute for Neurobiology, Magdeburg, Germany (Ms Behnisch and Dr Schott); Translational Psychiatry Tübingen, University Hospital Tübingen, Tübingen, Germany (Drs Liebe and Walter).,Correspondence: Martin Walter, MD, Head, Translational Psychiatry, General Psychiatry and Psychotherapy, Eberhard-Karls-University, Tübingen, Calwer Str. 14, 72076 Tübingen, Germany ()
| | - Shijia Li
- Clinical Affective Neuroimaging Laboratory, Leibniz Institute for Neurobiology, Magdeburg, Germany (Dr Liebe, Ms Colic, and Dr Krause); School of Psychology and Cognitive Science, East China Normal University, Shanghai, China (Dr Li); Department of Immunology, Queensland Institute of Medical Research, Herston, Queensland, Australia (Dr Lord); Department of Psychiatry and Psychotherapy, University Hospital Tübingen, Tübingen, Germany (Dr Batra); Department of Anesthesiology and Intensive Care Medicine (Dr Kretzschmar) and Neurocybernetics and Rehabilitation (Dr Sweeney-Reed), University Hospital, Magdeburg, Germany; Behavioural Neuroscience, Leibniz Institute for Neurobiology, Magdeburg, Germany (Ms Behnisch and Dr Schott); Translational Psychiatry Tübingen, University Hospital Tübingen, Tübingen, Germany (Drs Liebe and Walter)
| | - Anton Lord
- Clinical Affective Neuroimaging Laboratory, Leibniz Institute for Neurobiology, Magdeburg, Germany (Dr Liebe, Ms Colic, and Dr Krause); School of Psychology and Cognitive Science, East China Normal University, Shanghai, China (Dr Li); Department of Immunology, Queensland Institute of Medical Research, Herston, Queensland, Australia (Dr Lord); Department of Psychiatry and Psychotherapy, University Hospital Tübingen, Tübingen, Germany (Dr Batra); Department of Anesthesiology and Intensive Care Medicine (Dr Kretzschmar) and Neurocybernetics and Rehabilitation (Dr Sweeney-Reed), University Hospital, Magdeburg, Germany; Behavioural Neuroscience, Leibniz Institute for Neurobiology, Magdeburg, Germany (Ms Behnisch and Dr Schott); Translational Psychiatry Tübingen, University Hospital Tübingen, Tübingen, Germany (Drs Liebe and Walter)
| | - Lejla Colic
- Clinical Affective Neuroimaging Laboratory, Leibniz Institute for Neurobiology, Magdeburg, Germany (Dr Liebe, Ms Colic, and Dr Krause); School of Psychology and Cognitive Science, East China Normal University, Shanghai, China (Dr Li); Department of Immunology, Queensland Institute of Medical Research, Herston, Queensland, Australia (Dr Lord); Department of Psychiatry and Psychotherapy, University Hospital Tübingen, Tübingen, Germany (Dr Batra); Department of Anesthesiology and Intensive Care Medicine (Dr Kretzschmar) and Neurocybernetics and Rehabilitation (Dr Sweeney-Reed), University Hospital, Magdeburg, Germany; Behavioural Neuroscience, Leibniz Institute for Neurobiology, Magdeburg, Germany (Ms Behnisch and Dr Schott); Translational Psychiatry Tübingen, University Hospital Tübingen, Tübingen, Germany (Drs Liebe and Walter)
| | - Anna Linda Krause
- Clinical Affective Neuroimaging Laboratory, Leibniz Institute for Neurobiology, Magdeburg, Germany (Dr Liebe, Ms Colic, and Dr Krause); School of Psychology and Cognitive Science, East China Normal University, Shanghai, China (Dr Li); Department of Immunology, Queensland Institute of Medical Research, Herston, Queensland, Australia (Dr Lord); Department of Psychiatry and Psychotherapy, University Hospital Tübingen, Tübingen, Germany (Dr Batra); Department of Anesthesiology and Intensive Care Medicine (Dr Kretzschmar) and Neurocybernetics and Rehabilitation (Dr Sweeney-Reed), University Hospital, Magdeburg, Germany; Behavioural Neuroscience, Leibniz Institute for Neurobiology, Magdeburg, Germany (Ms Behnisch and Dr Schott); Translational Psychiatry Tübingen, University Hospital Tübingen, Tübingen, Germany (Drs Liebe and Walter)
| | - Anil Batra
- Clinical Affective Neuroimaging Laboratory, Leibniz Institute for Neurobiology, Magdeburg, Germany (Dr Liebe, Ms Colic, and Dr Krause); School of Psychology and Cognitive Science, East China Normal University, Shanghai, China (Dr Li); Department of Immunology, Queensland Institute of Medical Research, Herston, Queensland, Australia (Dr Lord); Department of Psychiatry and Psychotherapy, University Hospital Tübingen, Tübingen, Germany (Dr Batra); Department of Anesthesiology and Intensive Care Medicine (Dr Kretzschmar) and Neurocybernetics and Rehabilitation (Dr Sweeney-Reed), University Hospital, Magdeburg, Germany; Behavioural Neuroscience, Leibniz Institute for Neurobiology, Magdeburg, Germany (Ms Behnisch and Dr Schott); Translational Psychiatry Tübingen, University Hospital Tübingen, Tübingen, Germany (Drs Liebe and Walter)
| | - Moritz A Kretzschmar
- Clinical Affective Neuroimaging Laboratory, Leibniz Institute for Neurobiology, Magdeburg, Germany (Dr Liebe, Ms Colic, and Dr Krause); School of Psychology and Cognitive Science, East China Normal University, Shanghai, China (Dr Li); Department of Immunology, Queensland Institute of Medical Research, Herston, Queensland, Australia (Dr Lord); Department of Psychiatry and Psychotherapy, University Hospital Tübingen, Tübingen, Germany (Dr Batra); Department of Anesthesiology and Intensive Care Medicine (Dr Kretzschmar) and Neurocybernetics and Rehabilitation (Dr Sweeney-Reed), University Hospital, Magdeburg, Germany; Behavioural Neuroscience, Leibniz Institute for Neurobiology, Magdeburg, Germany (Ms Behnisch and Dr Schott); Translational Psychiatry Tübingen, University Hospital Tübingen, Tübingen, Germany (Drs Liebe and Walter)
| | - Catherine M Sweeney-Reed
- Clinical Affective Neuroimaging Laboratory, Leibniz Institute for Neurobiology, Magdeburg, Germany (Dr Liebe, Ms Colic, and Dr Krause); School of Psychology and Cognitive Science, East China Normal University, Shanghai, China (Dr Li); Department of Immunology, Queensland Institute of Medical Research, Herston, Queensland, Australia (Dr Lord); Department of Psychiatry and Psychotherapy, University Hospital Tübingen, Tübingen, Germany (Dr Batra); Department of Anesthesiology and Intensive Care Medicine (Dr Kretzschmar) and Neurocybernetics and Rehabilitation (Dr Sweeney-Reed), University Hospital, Magdeburg, Germany; Behavioural Neuroscience, Leibniz Institute for Neurobiology, Magdeburg, Germany (Ms Behnisch and Dr Schott); Translational Psychiatry Tübingen, University Hospital Tübingen, Tübingen, Germany (Drs Liebe and Walter)
| | - Gusalija Behnisch
- Clinical Affective Neuroimaging Laboratory, Leibniz Institute for Neurobiology, Magdeburg, Germany (Dr Liebe, Ms Colic, and Dr Krause); School of Psychology and Cognitive Science, East China Normal University, Shanghai, China (Dr Li); Department of Immunology, Queensland Institute of Medical Research, Herston, Queensland, Australia (Dr Lord); Department of Psychiatry and Psychotherapy, University Hospital Tübingen, Tübingen, Germany (Dr Batra); Department of Anesthesiology and Intensive Care Medicine (Dr Kretzschmar) and Neurocybernetics and Rehabilitation (Dr Sweeney-Reed), University Hospital, Magdeburg, Germany; Behavioural Neuroscience, Leibniz Institute for Neurobiology, Magdeburg, Germany (Ms Behnisch and Dr Schott); Translational Psychiatry Tübingen, University Hospital Tübingen, Tübingen, Germany (Drs Liebe and Walter)
| | - Björn H Schott
- Clinical Affective Neuroimaging Laboratory, Leibniz Institute for Neurobiology, Magdeburg, Germany (Dr Liebe, Ms Colic, and Dr Krause); School of Psychology and Cognitive Science, East China Normal University, Shanghai, China (Dr Li); Department of Immunology, Queensland Institute of Medical Research, Herston, Queensland, Australia (Dr Lord); Department of Psychiatry and Psychotherapy, University Hospital Tübingen, Tübingen, Germany (Dr Batra); Department of Anesthesiology and Intensive Care Medicine (Dr Kretzschmar) and Neurocybernetics and Rehabilitation (Dr Sweeney-Reed), University Hospital, Magdeburg, Germany; Behavioural Neuroscience, Leibniz Institute for Neurobiology, Magdeburg, Germany (Ms Behnisch and Dr Schott); Translational Psychiatry Tübingen, University Hospital Tübingen, Tübingen, Germany (Drs Liebe and Walter)
| | - Martin Walter
- Clinical Affective Neuroimaging Laboratory, Leibniz Institute for Neurobiology, Magdeburg, Germany (Dr Liebe, Ms Colic, and Dr Krause); School of Psychology and Cognitive Science, East China Normal University, Shanghai, China (Dr Li); Department of Immunology, Queensland Institute of Medical Research, Herston, Queensland, Australia (Dr Lord); Department of Psychiatry and Psychotherapy, University Hospital Tübingen, Tübingen, Germany (Dr Batra); Department of Anesthesiology and Intensive Care Medicine (Dr Kretzschmar) and Neurocybernetics and Rehabilitation (Dr Sweeney-Reed), University Hospital, Magdeburg, Germany; Behavioural Neuroscience, Leibniz Institute for Neurobiology, Magdeburg, Germany (Ms Behnisch and Dr Schott); Translational Psychiatry Tübingen, University Hospital Tübingen, Tübingen, Germany (Drs Liebe and Walter)
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Okamoto LE, Diedrich A, Baudenbacher FJ, Harder R, Whitfield JS, Iqbal F, Gamboa A, Shibao CA, Black BK, Raj SR, Robertson D, Biaggioni I. Efficacy of Servo-Controlled Splanchnic Venous Compression in the Treatment of Orthostatic Hypotension: A Randomized Comparison With Midodrine. Hypertension 2016; 68:418-26. [PMID: 27271310 DOI: 10.1161/hypertensionaha.116.07199] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2016] [Accepted: 03/31/2016] [Indexed: 11/16/2022]
Abstract
UNLABELLED Splanchnic venous pooling is a major hemodynamic determinant of orthostatic hypotension, but is not specifically targeted by pressor agents, the mainstay of treatment. We developed an automated inflatable abdominal binder that provides sustained servo-controlled venous compression (40 mm Hg) and can be activated only on standing. We tested the efficacy of this device against placebo and compared it to midodrine in 19 autonomic failure patients randomized to receive either placebo, midodrine (2.5-10 mg), or placebo combined with binder on separate days in a single-blind, crossover study. Systolic blood pressure (SBP) was measured seated and standing before and 1-hour post medication; the binder was inflated immediately before standing. Only midodrine increased seated SBP (31±5 versus 9±4 placebo and 7±5 binder, P=0.003), whereas orthostatic tolerance (defined as area under the curve of upright SBP [AUCSBP]) improved similarly with binder and midodrine (AUCSBP, 195±35 and 197±41 versus 19±38 mm Hg×minute for placebo; P=0.003). Orthostatic symptom burden decreased with the binder (from 21.9±3.6 to 16.3±3.1, P=0.032) and midodrine (from 25.6±3.4 to 14.2±3.3, P<0.001), but not with placebo (from 19.6±3.5 to 20.1±3.3, P=0.756). We also compared the combination of midodrine and binder with midodrine alone. The combination produced a greater increase in orthostatic tolerance (AUCSBP, 326±65 versus 140±53 mm Hg×minute for midodrine alone; P=0.028, n=21) and decreased orthostatic symptoms (from 21.8±3.2 to 12.9±2.9, P<0.001). In conclusion, servo-controlled abdominal venous compression with an automated inflatable binder is as effective as midodrine, the standard of care, in the management of orthostatic hypotension. Combining both therapies produces greater improvement in orthostatic tolerance. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov. Unique identifier: NCT00223691.
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Affiliation(s)
- Luis E Okamoto
- From the Vanderbilt Autonomic Dysfunction Center (L.E.O., A.D., A.G., C.A.S., B.K.B., S.R.R., D.R., I.B.), Division of Clinical Pharmacology (L.E.O., A.D., A.G., C.A.S., B.K.B., S.R.R., D.R., I.B.), Departments of Medicine (L.E.O., A.D., J.S.W., A.G., C.A.S., B.K.B., S.R.R., D.R., I.B.), Pharmacology (S.R.R., D.R., I.B.), Neurology (D.R.), Biomedical Engineering (A.D., F.J.B., F.I.), and Electrical Engineering (R.H.), Vanderbilt University School of Medicine, Nashville, TN
| | - André Diedrich
- From the Vanderbilt Autonomic Dysfunction Center (L.E.O., A.D., A.G., C.A.S., B.K.B., S.R.R., D.R., I.B.), Division of Clinical Pharmacology (L.E.O., A.D., A.G., C.A.S., B.K.B., S.R.R., D.R., I.B.), Departments of Medicine (L.E.O., A.D., J.S.W., A.G., C.A.S., B.K.B., S.R.R., D.R., I.B.), Pharmacology (S.R.R., D.R., I.B.), Neurology (D.R.), Biomedical Engineering (A.D., F.J.B., F.I.), and Electrical Engineering (R.H.), Vanderbilt University School of Medicine, Nashville, TN
| | - Franz J Baudenbacher
- From the Vanderbilt Autonomic Dysfunction Center (L.E.O., A.D., A.G., C.A.S., B.K.B., S.R.R., D.R., I.B.), Division of Clinical Pharmacology (L.E.O., A.D., A.G., C.A.S., B.K.B., S.R.R., D.R., I.B.), Departments of Medicine (L.E.O., A.D., J.S.W., A.G., C.A.S., B.K.B., S.R.R., D.R., I.B.), Pharmacology (S.R.R., D.R., I.B.), Neurology (D.R.), Biomedical Engineering (A.D., F.J.B., F.I.), and Electrical Engineering (R.H.), Vanderbilt University School of Medicine, Nashville, TN
| | - René Harder
- From the Vanderbilt Autonomic Dysfunction Center (L.E.O., A.D., A.G., C.A.S., B.K.B., S.R.R., D.R., I.B.), Division of Clinical Pharmacology (L.E.O., A.D., A.G., C.A.S., B.K.B., S.R.R., D.R., I.B.), Departments of Medicine (L.E.O., A.D., J.S.W., A.G., C.A.S., B.K.B., S.R.R., D.R., I.B.), Pharmacology (S.R.R., D.R., I.B.), Neurology (D.R.), Biomedical Engineering (A.D., F.J.B., F.I.), and Electrical Engineering (R.H.), Vanderbilt University School of Medicine, Nashville, TN
| | - Jonathan S Whitfield
- From the Vanderbilt Autonomic Dysfunction Center (L.E.O., A.D., A.G., C.A.S., B.K.B., S.R.R., D.R., I.B.), Division of Clinical Pharmacology (L.E.O., A.D., A.G., C.A.S., B.K.B., S.R.R., D.R., I.B.), Departments of Medicine (L.E.O., A.D., J.S.W., A.G., C.A.S., B.K.B., S.R.R., D.R., I.B.), Pharmacology (S.R.R., D.R., I.B.), Neurology (D.R.), Biomedical Engineering (A.D., F.J.B., F.I.), and Electrical Engineering (R.H.), Vanderbilt University School of Medicine, Nashville, TN
| | - Fahad Iqbal
- From the Vanderbilt Autonomic Dysfunction Center (L.E.O., A.D., A.G., C.A.S., B.K.B., S.R.R., D.R., I.B.), Division of Clinical Pharmacology (L.E.O., A.D., A.G., C.A.S., B.K.B., S.R.R., D.R., I.B.), Departments of Medicine (L.E.O., A.D., J.S.W., A.G., C.A.S., B.K.B., S.R.R., D.R., I.B.), Pharmacology (S.R.R., D.R., I.B.), Neurology (D.R.), Biomedical Engineering (A.D., F.J.B., F.I.), and Electrical Engineering (R.H.), Vanderbilt University School of Medicine, Nashville, TN
| | - Alfredo Gamboa
- From the Vanderbilt Autonomic Dysfunction Center (L.E.O., A.D., A.G., C.A.S., B.K.B., S.R.R., D.R., I.B.), Division of Clinical Pharmacology (L.E.O., A.D., A.G., C.A.S., B.K.B., S.R.R., D.R., I.B.), Departments of Medicine (L.E.O., A.D., J.S.W., A.G., C.A.S., B.K.B., S.R.R., D.R., I.B.), Pharmacology (S.R.R., D.R., I.B.), Neurology (D.R.), Biomedical Engineering (A.D., F.J.B., F.I.), and Electrical Engineering (R.H.), Vanderbilt University School of Medicine, Nashville, TN
| | - Cyndya A Shibao
- From the Vanderbilt Autonomic Dysfunction Center (L.E.O., A.D., A.G., C.A.S., B.K.B., S.R.R., D.R., I.B.), Division of Clinical Pharmacology (L.E.O., A.D., A.G., C.A.S., B.K.B., S.R.R., D.R., I.B.), Departments of Medicine (L.E.O., A.D., J.S.W., A.G., C.A.S., B.K.B., S.R.R., D.R., I.B.), Pharmacology (S.R.R., D.R., I.B.), Neurology (D.R.), Biomedical Engineering (A.D., F.J.B., F.I.), and Electrical Engineering (R.H.), Vanderbilt University School of Medicine, Nashville, TN
| | - Bonnie K Black
- From the Vanderbilt Autonomic Dysfunction Center (L.E.O., A.D., A.G., C.A.S., B.K.B., S.R.R., D.R., I.B.), Division of Clinical Pharmacology (L.E.O., A.D., A.G., C.A.S., B.K.B., S.R.R., D.R., I.B.), Departments of Medicine (L.E.O., A.D., J.S.W., A.G., C.A.S., B.K.B., S.R.R., D.R., I.B.), Pharmacology (S.R.R., D.R., I.B.), Neurology (D.R.), Biomedical Engineering (A.D., F.J.B., F.I.), and Electrical Engineering (R.H.), Vanderbilt University School of Medicine, Nashville, TN
| | - Satish R Raj
- From the Vanderbilt Autonomic Dysfunction Center (L.E.O., A.D., A.G., C.A.S., B.K.B., S.R.R., D.R., I.B.), Division of Clinical Pharmacology (L.E.O., A.D., A.G., C.A.S., B.K.B., S.R.R., D.R., I.B.), Departments of Medicine (L.E.O., A.D., J.S.W., A.G., C.A.S., B.K.B., S.R.R., D.R., I.B.), Pharmacology (S.R.R., D.R., I.B.), Neurology (D.R.), Biomedical Engineering (A.D., F.J.B., F.I.), and Electrical Engineering (R.H.), Vanderbilt University School of Medicine, Nashville, TN
| | - David Robertson
- From the Vanderbilt Autonomic Dysfunction Center (L.E.O., A.D., A.G., C.A.S., B.K.B., S.R.R., D.R., I.B.), Division of Clinical Pharmacology (L.E.O., A.D., A.G., C.A.S., B.K.B., S.R.R., D.R., I.B.), Departments of Medicine (L.E.O., A.D., J.S.W., A.G., C.A.S., B.K.B., S.R.R., D.R., I.B.), Pharmacology (S.R.R., D.R., I.B.), Neurology (D.R.), Biomedical Engineering (A.D., F.J.B., F.I.), and Electrical Engineering (R.H.), Vanderbilt University School of Medicine, Nashville, TN
| | - Italo Biaggioni
- From the Vanderbilt Autonomic Dysfunction Center (L.E.O., A.D., A.G., C.A.S., B.K.B., S.R.R., D.R., I.B.), Division of Clinical Pharmacology (L.E.O., A.D., A.G., C.A.S., B.K.B., S.R.R., D.R., I.B.), Departments of Medicine (L.E.O., A.D., J.S.W., A.G., C.A.S., B.K.B., S.R.R., D.R., I.B.), Pharmacology (S.R.R., D.R., I.B.), Neurology (D.R.), Biomedical Engineering (A.D., F.J.B., F.I.), and Electrical Engineering (R.H.), Vanderbilt University School of Medicine, Nashville, TN.
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McDonell KE, Shibao CA, Claassen DO. Clinical Relevance of Orthostatic Hypotension in Neurodegenerative Disease. Curr Neurol Neurosci Rep 2016; 15:78. [PMID: 26486792 DOI: 10.1007/s11910-015-0599-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
The autonomic nervous system appears to be uniquely susceptible to degeneration in disorders of α-synuclein pathology. Clinically, autonomic dysfunction in these disorders manifests as neurogenic orthostatic hypotension (nOH), a condition that results in substantial morbidity and mortality. nOH results from pathology affecting either the central autonomic pathways or peripheral autonomic nerve fibers. Determining the localization and pathophysiology of nOH is critical in effectively managing this disorder and selecting appropriate treatment options. In this review, we discuss the pathophysiology of nOH with respect to the various α-synuclein-related neurodegenerative conditions. We highlight the associated clinical features, including gait instability, rapid eye movement behavior disorder, and hyposmia. We also review the current pharmacologic treatment options for nOH. Overall, the goals of therapy are to improve symptoms and prevent syncope and falls. Non-pharmacologic interventions should be introduced first, followed by carefully selected pharmacologic therapies. Treatment decisions should be directed by an understanding of the underlying pathophysiology, as well as the comorbidities and potential contributing factors present in each individual patient.
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Affiliation(s)
- Katherine E McDonell
- Department of Neurology, Vanderbilt University Medical Center, 1161 21st Avenue South A-0118, Nashville, TN, 37232-2551, USA.
| | - Cyndya A Shibao
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Daniel O Claassen
- Department of Neurology, Vanderbilt University Medical Center, 1161 21st Avenue South A-0118, Nashville, TN, 37232-2551, USA
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Loavenbruck A, Sandroni P. Neurogenic orthostatic hypotension: roles of norepinephrine deficiency in its causes, its treatment, and future research directions. Curr Med Res Opin 2015; 31:2095-104. [PMID: 26373628 DOI: 10.1185/03007995.2015.1087988] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Although a diversity of neurotransmitters and hormones participate in controlling blood pressure, norepinephrine released from postganglionic sympathetic nerve terminals is an important mediator of the rapid regulation of cardiovascular function required for homeostasis of cerebral perfusion. Hence, neurogenic orthostatic hypotension (NOH) often represents a deficiency of noradrenergic responsiveness to postural change. RESEARCH DESIGN AND METHODS PubMed searches with 'orthostatic hypotension' and 'norepinephrine' as conjoint search terms and no restriction on language or date, so as to survey the pathophysiologic and clinical relevance of norepinephrine deficiency for current NOH interventions and for future directions in treatment and research. RESULTS Norepinephrine deficiency in NOH can arise peripherally, due to cardiovascular sympathetic denervation (as in pure autonomic failure, Parkinson's disease, and a variety of neuropathies), or centrally, due to a failure of viscerosensory signals to generate adequate sympathetic traffic to intact sympathetic nerve endings (as in multiple system atrophy). Nonpharmacologic countermeasures such as pre-emptive water intake may yield blood-pressure increases exceeding those achieved pharmacologically. For patients with symptomatic NOH unresponsive to such strategies, a variety of pharmacologic interventions have been administered off-label on the basis of drug mechanisms expected to increase blood pressure via blood-volume expansion or vasoconstriction. Two pressor agents have received FDA approval: the sympathomimetic midodrine and more recently the norepinephrine prodrug droxidopa. CONCLUSIONS Pressor agents are important for treating symptomatic NOH in patients unresponsive to lifestyle changes alone. However, the dysautonomia underlying NOH often permits blood-pressure excursions toward both hypotension and hypertension. Future research should aim to shed light on the resulting management issues, and should also explore the possibility of pharmacotherapy selectively targeting orthostatic blood-pressure decreases.
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Affiliation(s)
- Adam Loavenbruck
- a a Department of Neurology , University of Minnesota , Minneapolis , MN , USA
| | - Paola Sandroni
- b b Department of Neurology , Mayo Clinic , Rochester , MN , USA
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Alagiakrishnan K. Current Pharmacological Management of Hypotensive Syndromes in the Elderly. Drugs Aging 2015; 32:337-48. [DOI: 10.1007/s40266-015-0263-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Abstract
Orthostatic hypotension is common in Parkinson's disease. The current recommended management of orthostatic hypotension related to Parkinson's disease involves first general measures and then medications with little risk of severe adverse side effects.
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Affiliation(s)
- Connie K Wu
- Department of Neurology, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Anna D Hohler
- Department of Neurology, Boston University School of Medicine, Boston, Massachusetts, USA
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Okamoto LE, Gamboa A, Shibao CA, Arnold AC, Choi L, Black BK, Raj SR, Robertson D, Biaggioni I. Nebivolol, but not metoprolol, lowers blood pressure in nitric oxide-sensitive human hypertension. Hypertension 2014; 64:1241-7. [PMID: 25267802 DOI: 10.1161/hypertensionaha.114.04116] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Nebivolol, unlike other selective β1-receptor blockers, induces vasodilation attributable to increased NO bioavailability. The relative contribution of this mechanism to the blood pressure (BP)-lowering effects of nebivolol is unclear because it is normally masked by baroreflex buffering. Autonomic failure provides a unique model of hypertension devoid of autonomic modulation but sensitive to the hypotensive effects of NO potentiation. We tested the hypothesis that nebivolol would decrease BP in these patients through a mechanism independent of β-blockade. We randomized 20 autonomic failure patients with supine hypertension (14 men; 69±2 years) to receive a single oral dose of placebo, nebivolol 5 mg, metoprolol 50 mg (negative control), and sildenafil 25 mg (positive control) on separate nights in a double-blind, crossover study. Supine BP was monitored every 2 hours from 8:00 pm to 8:00 am. Compared with placebo, sildenafil and nebivolol decreased systolic BP during the night (P<0.001 and P=0.036, by mixed-effects model, maximal systolic BP reduction 8-hour postdrug of -20±6 and -24±9 mm Hg, respectively), whereas metoprolol had no effect. In a subanalysis, we divided patients into sildenafil responders (BP fall>20 mm Hg at 4:00 am) and nonresponders. Nebivolol significantly lowered systolic BP in sildenafil responders (-44±13 mm Hg) but not in nonresponders (1±11 mm Hg). Despite lowering nighttime BP, nebivolol did not worsen morning orthostatic tolerance compared with placebo. In conclusion, nebivolol effectively lowered supine hypertension in autonomic failure, independent of β1-blockade. These results are consistent with the hypothesis that NO potentiation contributes significantly to the antihypertensive effect of nebivolol.
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Affiliation(s)
- Luis E Okamoto
- From the Vanderbilt Autonomic Dysfunction Center and Division of Clinical Pharmacology, Department of Medicine (L.E.O., A.G., C.A.S., A.C.A., B.K.B., S.R.R., D.R., I.B.), and Departments of Pharmacology (S.R.R., D.R., I.B.), Neurology (D.R.), and Biostatistics (L.C.), Vanderbilt University School of Medicine, Nashville, TN
| | - Alfredo Gamboa
- From the Vanderbilt Autonomic Dysfunction Center and Division of Clinical Pharmacology, Department of Medicine (L.E.O., A.G., C.A.S., A.C.A., B.K.B., S.R.R., D.R., I.B.), and Departments of Pharmacology (S.R.R., D.R., I.B.), Neurology (D.R.), and Biostatistics (L.C.), Vanderbilt University School of Medicine, Nashville, TN
| | - Cyndya A Shibao
- From the Vanderbilt Autonomic Dysfunction Center and Division of Clinical Pharmacology, Department of Medicine (L.E.O., A.G., C.A.S., A.C.A., B.K.B., S.R.R., D.R., I.B.), and Departments of Pharmacology (S.R.R., D.R., I.B.), Neurology (D.R.), and Biostatistics (L.C.), Vanderbilt University School of Medicine, Nashville, TN
| | - Amy C Arnold
- From the Vanderbilt Autonomic Dysfunction Center and Division of Clinical Pharmacology, Department of Medicine (L.E.O., A.G., C.A.S., A.C.A., B.K.B., S.R.R., D.R., I.B.), and Departments of Pharmacology (S.R.R., D.R., I.B.), Neurology (D.R.), and Biostatistics (L.C.), Vanderbilt University School of Medicine, Nashville, TN
| | - Leena Choi
- From the Vanderbilt Autonomic Dysfunction Center and Division of Clinical Pharmacology, Department of Medicine (L.E.O., A.G., C.A.S., A.C.A., B.K.B., S.R.R., D.R., I.B.), and Departments of Pharmacology (S.R.R., D.R., I.B.), Neurology (D.R.), and Biostatistics (L.C.), Vanderbilt University School of Medicine, Nashville, TN
| | - Bonnie K Black
- From the Vanderbilt Autonomic Dysfunction Center and Division of Clinical Pharmacology, Department of Medicine (L.E.O., A.G., C.A.S., A.C.A., B.K.B., S.R.R., D.R., I.B.), and Departments of Pharmacology (S.R.R., D.R., I.B.), Neurology (D.R.), and Biostatistics (L.C.), Vanderbilt University School of Medicine, Nashville, TN
| | - Satish R Raj
- From the Vanderbilt Autonomic Dysfunction Center and Division of Clinical Pharmacology, Department of Medicine (L.E.O., A.G., C.A.S., A.C.A., B.K.B., S.R.R., D.R., I.B.), and Departments of Pharmacology (S.R.R., D.R., I.B.), Neurology (D.R.), and Biostatistics (L.C.), Vanderbilt University School of Medicine, Nashville, TN
| | - David Robertson
- From the Vanderbilt Autonomic Dysfunction Center and Division of Clinical Pharmacology, Department of Medicine (L.E.O., A.G., C.A.S., A.C.A., B.K.B., S.R.R., D.R., I.B.), and Departments of Pharmacology (S.R.R., D.R., I.B.), Neurology (D.R.), and Biostatistics (L.C.), Vanderbilt University School of Medicine, Nashville, TN
| | - Italo Biaggioni
- From the Vanderbilt Autonomic Dysfunction Center and Division of Clinical Pharmacology, Department of Medicine (L.E.O., A.G., C.A.S., A.C.A., B.K.B., S.R.R., D.R., I.B.), and Departments of Pharmacology (S.R.R., D.R., I.B.), Neurology (D.R.), and Biostatistics (L.C.), Vanderbilt University School of Medicine, Nashville, TN.
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Arnold AC, Ramirez CE, Choi L, Okamoto LE, Gamboa A, Diedrich A, Raj SR, Robertson D, Biaggioni I, Shibao CA. Combination ergotamine and caffeine improves seated blood pressure and presyncopal symptoms in autonomic failure. Front Physiol 2014; 5:270. [PMID: 25104940 PMCID: PMC4109567 DOI: 10.3389/fphys.2014.00270] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Accepted: 06/30/2014] [Indexed: 11/29/2022] Open
Abstract
Severely affected patients with autonomic failure require pressor agents to counteract the blood pressure fall and improve presyncopal symptoms upon standing. Previous studies suggest that combination ergotamine and caffeine may be effective in the treatment of autonomic failure, but the efficacy of this drug has not been evaluated in controlled trials. Therefore, we compared the effects of ergotamine/caffeine on seated blood pressure and orthostatic tolerance and symptoms in 12 primary autonomic failure patients without history of coronary artery disease. Patients were randomized to receive a single oral dose of placebo, midodrine (5–10 mg), or ergotamine and caffeine (1 and 100 mg, respectively) in a single-blind, crossover study. Blood pressure was measured while patients were seated and after standing for up to 10 min, at baseline and at 1 h post-drug. Ergotamine/caffeine increased seated systolic blood pressure (SBP), the primary outcome, compared with placebo (131 ± 19 and 95 ± 12 mmHg, respectively, at 1 h post-drug; p = 0.003 for time effect). Midodrine also significantly increased seated SBP (121 ± 19 mmHg at 1 h post-drug; p = 0.015 for time effect vs. placebo), but this effect was not different from ergotamine/caffeine (p = 0.621). There was no significant effect of either medication on orthostatic tolerance; however, ergotamine/caffeine improved presyncopal symptoms (p = 0.034). These findings suggest that combination ergotamine and caffeine elicits a seated pressor response that is similar in magnitude to midodrine, and improves symptoms in autonomic failure. Thus, ergotamine/caffeine could be used as an alternate treatment for autonomic failure, in carefully selected patients without comorbid coronary artery disease.
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Affiliation(s)
- Amy C Arnold
- Division of Clinical Pharmacology, Department of Medicine, Autonomic Dysfunction Center, Vanderbilt University School of Medicine Nashville, TN, USA
| | - Claudia E Ramirez
- Division of Clinical Pharmacology, Department of Medicine, Autonomic Dysfunction Center, Vanderbilt University School of Medicine Nashville, TN, USA
| | - Leena Choi
- Department of Biostatistics, Vanderbilt University School of Medicine Nashville, TN, USA
| | - Luis E Okamoto
- Division of Clinical Pharmacology, Department of Medicine, Autonomic Dysfunction Center, Vanderbilt University School of Medicine Nashville, TN, USA
| | - Alfredo Gamboa
- Division of Clinical Pharmacology, Department of Medicine, Autonomic Dysfunction Center, Vanderbilt University School of Medicine Nashville, TN, USA
| | - André Diedrich
- Division of Clinical Pharmacology, Department of Medicine, Autonomic Dysfunction Center, Vanderbilt University School of Medicine Nashville, TN, USA
| | - Satish R Raj
- Division of Clinical Pharmacology, Department of Medicine, Autonomic Dysfunction Center, Vanderbilt University School of Medicine Nashville, TN, USA
| | - David Robertson
- Division of Clinical Pharmacology, Department of Medicine, Autonomic Dysfunction Center, Vanderbilt University School of Medicine Nashville, TN, USA
| | - Italo Biaggioni
- Division of Clinical Pharmacology, Department of Medicine, Autonomic Dysfunction Center, Vanderbilt University School of Medicine Nashville, TN, USA
| | - Cyndya A Shibao
- Division of Clinical Pharmacology, Department of Medicine, Autonomic Dysfunction Center, Vanderbilt University School of Medicine Nashville, TN, USA
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Isaacson SH, Skettini J. Neurogenic orthostatic hypotension in Parkinson's disease: evaluation, management, and emerging role of droxidopa. Vasc Health Risk Manag 2014; 10:169-76. [PMID: 24729712 PMCID: PMC3979788 DOI: 10.2147/vhrm.s53983] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Neurogenic orthostatic hypotension (nOH) is due to failure of the autonomic nervous system to regulate blood pressure in response to postural changes due to an inadequate release of norepinephrine, leading to orthostatic hypotension and supine hypertension. nOH is common in Parkinson’s disease (PD). Prevalence varies throughout the course of PD, ranging from 40% to 60%, and resulting in symptomatic nOH in approximately half. Symptomatic nOH, including lightheadedness, can limit daily activities and lead to falls. Symptomatic nOH can also limit therapeutic options for treating PD motor symptoms. Clinical evaluation should routinely include symptom assessment and blood pressure measurement of supine, sitting, and 3-minute standing; 24-hour ambulatory blood pressure monitoring can also be helpful. Non-pharmacological management of symptomatic nOH involves education, physical maneuvers, and adequate hydration. Current pharmacological treatment of symptomatic nOH includes salt supplement, fludrocortisone, midodrine, pyridostigmine, and other empiric medications. Despite these options, treatment of symptomatic nOH remains suboptimal, often limited by severe increases in supine blood pressure. Droxidopa, an oral prodrug converted by decarboxylation to norepinephrine, is a promising therapeutic option for symptomatic nOH in PD, improving symptoms of nOH, daily activities, falls, and standing systolic blood pressure in several recent trials. These trials demonstrated short-term efficacy and tolerability, with comparable increases in standing and supine blood pressures. Longer-term studies are ongoing to confirm durability of treatment effect.
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Affiliation(s)
- Stuart H Isaacson
- Parkinson's Disease and Movement Disorders Center of Boca Raton, Boca Raton, FL, USA
| | - Julia Skettini
- Parkinson's Disease and Movement Disorders Center of Boca Raton, Boca Raton, FL, USA
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Shibao C, Muppa P, Semler MW, Peltier AC, Biaggioni I. A standing dilemma: autonomic failure preceding Hodgkin's lymphoma. Am J Med 2014; 127:284-7. [PMID: 24333616 PMCID: PMC4099002 DOI: 10.1016/j.amjmed.2013.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2013] [Revised: 12/03/2013] [Accepted: 12/03/2013] [Indexed: 10/25/2022]
Affiliation(s)
- Cyndya Shibao
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn; Autonomic Dysfunction Center, Vanderbilt University Medical Center, Nashville, Tenn
| | - Prasuna Muppa
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Matthew W Semler
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Amanda C Peltier
- Department of Neurology, Vanderbilt University Medical Center, Nashville, Tenn
| | - Italo Biaggioni
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn; Autonomic Dysfunction Center, Vanderbilt University Medical Center, Nashville, Tenn.
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Abstract
Orthostatic hypotension is a condition commonly affecting the elderly and is often accompanied by disabling presyncopal symptoms, syncope and impaired quality of life. The pathophysiology of orthostatic hypotension is linked to abnormal blood pressure regulatory mechanisms and autonomic insufficiency. As part of its diagnostic evaluation, a comprehensive history and medical examination focused on detecting symptoms and physical findings of autonomic neuropathy should be performed. In individuals with substantial falls in blood pressure upon standing, autonomic function tests are recommended to detect impairment of autonomic reflexes. Treatment should always follow a stepwise approach with initial use of nonpharmacologic interventions including avoidance of hypotensive medications, high-salt diet and physical counter maneuvers. If these measures are not sufficient, medications such as fludrocortisone and midodrine can be added. The goals of treatment are to improve symptoms and to make the patient as ambulatory as possible instead of targeting arbitrary blood pressure values.
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Affiliation(s)
- Amy C Arnold
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University School of Medicine, 562 Preston Research Building, Nashville, TN 37232-8802, USA
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Schroeder C, Jordan J, Kaufmann H. Management of neurogenic orthostatic hypotension in patients with autonomic failure. Drugs 2014; 73:1267-79. [PMID: 23857549 DOI: 10.1007/s40265-013-0097-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The maintenance of blood pressure in the upright position requires intact autonomic cardiovascular reflexes. Diseases that affect the sympathetic innervation of the cardiovascular system result in a sustained fall in blood pressure upon standing (i.e., neurogenic orthostatic hypotension) that can impair the blood supply to the brain and other organs and cause considerable morbidity and mortality. Here we review treatment options for neurogenic orthostatic hypotension and include an algorithm for its management that emphasizes the importance of non-pharmacologic measures and provides guidance on pharmacologic treatment options.
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Affiliation(s)
- Christoph Schroeder
- Institute of Clinical Pharmacology, OE 5350, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625, Germany.
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40
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Stewart JM. Update on the theory and management of orthostatic intolerance and related syndromes in adolescents and children. Expert Rev Cardiovasc Ther 2013; 10:1387-99. [PMID: 23244360 DOI: 10.1586/erc.12.139] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Orthostasis means standing upright. One speaks of orthostatic intolerance (OI) when signs, such as hypotension, and symptoms, such as lightheadedness, occur when upright and are relieved by recumbence. The experience of transient mild OI is part of daily life. 'Initial orthostatic hypotension' on rapid standing is a normal form of OI. However, other people experience OI that seriously interferes with quality of life. These include episodic acute OI, in the form of postural vasovagal syncope, and chronic OI, in the form of postural tachycardia syndrome. Less common is neurogenic orthostatic hypotension, which is an aspect of autonomic failure. Normal orthostatic physiology and potential mechanisms for OI are discussed, including forms of sympathetic hypofunction, forms of sympathetic hyperfunction and OI that results from regional blood volume redistribution. General and specific treatment options are proposed.
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Affiliation(s)
- Julian M Stewart
- Departments of Pediatrics, Physiology and Medicine, The Maria Fareri Childrens Hospital and New York Medical College, Valhalla, NY, USA.
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Affiliation(s)
- Michael G. Ziegler
- From the Department of Medicine, University of California San Diego, San Diego, CA
| | - Milos Milic
- From the Department of Medicine, University of California San Diego, San Diego, CA
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