101
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Dispenzieri A, Buadi F, Kumar SK, Reeder CB, Sher T, Lacy MQ, Kyle RA, Mikhael JR, Roy V, Leung N, Grogan M, Kapoor P, Lust JA, Dingli D, Go RS, Hwa YL, Hayman SR, Fonseca R, Ailawadhi S, Bergsagel PL, Chanan-Khan A, Rajkumar SV, Russell SJ, Stewart K, Zeldenrust SR, Gertz MA. Treatment of Immunoglobulin Light Chain Amyloidosis: Mayo Stratification of Myeloma and Risk-Adapted Therapy (mSMART) Consensus Statement. Mayo Clin Proc 2015; 90:1054-81. [PMID: 26250727 DOI: 10.1016/j.mayocp.2015.06.009] [Citation(s) in RCA: 91] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Revised: 06/10/2015] [Accepted: 06/11/2015] [Indexed: 01/19/2023]
Abstract
Immunoglobulin light chain amyloidosis (AL amyloidosis) has an incidence of approximately 1 case per 100,000 person-years in Western countries. The rarity of the condition not only poses a challenge for making a prompt diagnosis but also makes evidenced decision making about treatment even more challenging. Physicians caring for patients with AL amyloidosis have been borrowing and customizing the therapies used for patients with multiple myeloma with varying degrees of success. One of the biggest failings in the science of the treatment of AL amyloidosis is the paucity of prospective trials, especially phase 3 trials. Herein, we present an extensive review of the literature with an aim of making recommendations in the context of the best evidence and expert opinion.
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Affiliation(s)
| | | | | | - Craig B Reeder
- Division of Hematology/Oncology, Mayo Clinic, Scottsdale, AZ
| | - Tamur Sher
- Division of Hematology/Oncology, Mayo Clinic, Jacksonville, FL
| | | | | | | | - Vivek Roy
- Division of Hematology/Oncology, Mayo Clinic, Jacksonville, FL
| | - Nelson Leung
- Division of Hematology, Mayo Clinic, Rochester, MN
| | - Martha Grogan
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | | | - John A Lust
- Division of Hematology, Mayo Clinic, Rochester, MN
| | - David Dingli
- Division of Hematology, Mayo Clinic, Rochester, MN
| | - Ronald S Go
- Division of Hematology, Mayo Clinic, Rochester, MN
| | - Yi Lisa Hwa
- Division of Hematology, Mayo Clinic, Rochester, MN
| | | | - Rafael Fonseca
- Division of Hematology/Oncology, Mayo Clinic, Scottsdale, AZ
| | | | | | | | | | | | - Keith Stewart
- Division of Hematology/Oncology, Mayo Clinic, Scottsdale, AZ
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102
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Low PA, Tomalia VA. Orthostatic Hypotension: Mechanisms, Causes, Management. J Clin Neurol 2015; 11:220-6. [PMID: 26174784 PMCID: PMC4507375 DOI: 10.3988/jcn.2015.11.3.220] [Citation(s) in RCA: 90] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Revised: 01/20/2015] [Accepted: 01/20/2015] [Indexed: 12/13/2022] Open
Abstract
Orthostatic hypotension (OH) occurs when mechanisms for the regulation of orthostatic BP control fails. Such regulation depends on the baroreflexes, normal blood volume, and defenses against excessive venous pooling. OH is common in the elderly and is associated with an increase in mortality rate. There are many causes of OH. Aging coupled with diseases such as diabetes and Parkinson's disease results in a prevalence of 10-30% in the elderly. These conditions cause baroreflex failure with resulting combination of OH, supine hypertension, and loss of diurnal variation of BP. The treatment of OH is imperfect since it is impossible to normalize standing BP without generating excessive supine hypertension. The practical goal is to improve standing BP so as to minimize symptoms and to improve standing time in order to be able to undertake orthostatic activities of daily living, without excessive supine hypertension. It is possible to achieve these goals with a combination of fludrocortisone, a pressor agent (midodrine or droxidopa), supplemented with procedures to improve orthostatic defenses during periods of increased orthostatic stress. Such procedures include water bolus treatment and physical countermaneuvers. We provide a pragmatic guide on patient education and the patient-orientated approach to the moment to moment management of OH.
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Affiliation(s)
- Phillip A Low
- Department of Neurology, Mayo Clinic, Rochester, MN, USA.
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103
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Abstract
Neurogenic orthostatic hypotension (nOH) is a fall in blood pressure (BP) on standing due to reduced norepinephrine release from sympathetic nerve terminals. nOH is a feature of several neurological disorders that affect the autonomic nervous system, most notably Parkinson disease (PD), multiple system atrophy (MSA), pure autonomic failure (PAF), and other autonomic neuropathies. Droxidopa, an orally active synthetic amino acid that is converted to norepinephrine by the enzyme aromatic L-amino acid decarboxylase (dopa-decarboxylase), was recently approved by the FDA for the short-term treatment of nOH. It is presumed to raise BP by acting at the neurovascular junction to increase vascular tone. This article summarizes the pharmacological properties of droxidopa, its mechanism of action, and the efficacy and safety results of clinical trials.
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Affiliation(s)
- Horacio Kaufmann
- Department of Neurology, New York University School of Medicine, New York, NY, USA
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104
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Abstract
Dementia with Lewy bodies is an under-recognized disease; it is responsible for up to 20 % of all dementia cases. Accurate diagnosis is essential because the management of dementia with Lewy bodies is more complex than many neurodegenerative diseases. This is because alpha-synuclein, the pathological protein responsible for dementia with Lewy bodies (and Parkinson's disease), produces symptoms in multiple domains. By dividing the symptoms into cognitive, neuropsychiatric, movement, autonomic, and sleep categories, a comprehensive treatment strategy can be achieved. Management decisions are complex, since the treatment of one set of symptoms can cause complications in other symptom domains. Nevertheless, a comprehensive treatment program can greatly improve the patient's quality of life, but does not alter the progression of disease. Cholinesterase inhibitors are effective for cognitive and neuropsychiatric symptoms; rivastigmine has the widest evidence base. Special care needs to be taken to avoid potentially fatal idiopathic reactions to neuroleptic medications; these should be used for short periods only when absolutely necessary and when alternative treatments have failed. Pimavanserin, a selective serotonin 5-HT2A inverse agonist, holds promise as an alternative therapy for synuclein-associated psychosis. Levodopa/carbidopa treatment of parkinsonism is often limited by dopa-induced exacerbations of neuropsychiatric and cognitive symptoms. Autonomic symptoms are under-recognized complications of synucleinopathy. Constipation, urinary symptoms and postural hypotension respond to standard medications. Rapid eye movement sleep behavior disorder is highly specific (98 %) to the synucleinopathies. Nonpharmacological treatments, melatonin and clonazepam are all effective.
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Affiliation(s)
- Brendon P Boot
- Department of Neurology, Brigham and Women's Hospital, 221 Longwood Avenue, Boston, MA 02115 USA ; Harvard Medical School, 25 Shattuck Street, Boston, MA 02115 USA
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105
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Kuritzky L, Espay AJ, Gelblum J, Payne R, Dietrich E. Diagnosing and treating neurogenic orthostatic hypotension in primary care. Postgrad Med 2015; 127:702-15. [PMID: 26012731 DOI: 10.1080/00325481.2015.1050340] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
In response to a change in posture from supine or sitting to standing, autonomic reflexes normally maintain blood pressure (BP) by selective increases in arteriovenous resistance and by increased cardiac output, ensuring continued perfusion of the central nervous system. In neurogenic orthostatic hypotension (NOH), inadequate vasoconstriction and cardiac output cause BP to drop excessively, resulting in inadequate perfusion, with predictable symptoms such as dizziness, lightheadedness and falls. The condition may represent a central failure of baroreceptor signals to modulate cardiovascular function, a peripheral failure of norepinephrine release from cardiovascular sympathetic nerve endings, or both. Symptomatic patients may benefit from both non-pharmacologic and pharmacologic interventions. Among the latter, two pressor agents have been approved by the US Food and Drug Administration: the sympathomimetic prodrug midodrine, approved in 1996 for symptomatic orthostatic hypotension, and the norepinephrine prodrug droxidopa, approved in 2014, which is indicated for the treatment of symptomatic neurogenic orthostatic hypotension caused by primary autonomic failure (Parkinson's disease, multiple system atrophy and pure autonomic failure). A wide variety of off-label options also have been described (e.g. the synthetic mineralocorticoid fludrocortisone). Because pressor agents may promote supine hypertension, NOH management requires monitoring of supine BP and also lifestyle measures to minimize supine BP increases (e.g. head-of-bed elevation). However, NOH has been associated with cognitive impairment and increases a patient's risk of syncope and falls, with the potential for serious consequences. Hence, concerns about supine hypertension - for which the long-term prognosis in patients with NOH is yet to be established - must sometimes be balanced by the need to address a patient's immediate risks.
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Affiliation(s)
- Louis Kuritzky
- a 1 Department of Community Health and Family Medicine, University of Florida , Gainesville, FL, USA
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106
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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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107
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Figueroa JJ, Singer W, Sandroni P, Sletten DM, Gehrking TL, Gehrking JA, Low P, Basford JR. Effects of patient-controlled abdominal compression on standing systolic blood pressure in adults with orthostatic hypotension. Arch Phys Med Rehabil 2015; 96:505-10. [PMID: 25448247 PMCID: PMC4339489 DOI: 10.1016/j.apmr.2014.10.012] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2014] [Revised: 10/13/2014] [Accepted: 10/16/2014] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To assess the effects of patient-controlled abdominal compression on postural changes in systolic blood pressure (SBP) associated with orthostatic hypotension (OH). Secondary variables included subject assessments of their preferences and the ease-of-use. DESIGN Randomized crossover trial. SETTING Clinical research laboratory. PARTICIPANTS Adults with neurogenic OH (N=13). INTERVENTIONS Four maneuvers were performed: moving from supine to standing without abdominal compression; moving from supine to standing with either a conventional or an adjustable abdominal binder in place; application of subject-determined maximal tolerable abdominal compression while standing; and while still erect, subsequent reduction of abdominal compression to a level the subject believed would be tolerable for a prolonged period. MAIN OUTCOME MEASURES The primary outcome variable included postural changes in SBP. Secondary outcome variables included subject assessments of their preferences and ease of use. RESULTS Baseline median SBP in the supine position was not affected by mild (10mmHg) abdominal compression prior to rising (without abdominal compression: 146mmHg; interquartile range, 124-164mmHg; with the conventional binder: 145mmHg; interquartile range, 129-167mmHg; with the adjustable binder: 153mmHg, interquartile range, 129-160mmHg; P=.85). Standing without a binder was associated with an -57mmHg (interquartile range, -40 to -76mmHg) SBP decrease. Levels of compression of 10mmHg applied prior to rising with the conventional and adjustable binders blunted these drops to -50mmHg (interquartile range, -33 to -70mmHg; P=.03) and -46mmHg (interquartile range, -34 to -75mmHg; P=.01), respectively. Increasing compression to subject-selected maximal tolerance while standing did not provide additional benefit and was associated with drops of -53mmHg (interquartile range, -26 to -71mmHg; P=.64) and -59mmHg (interquartile range, -49 to -76mmHg; P=.52) for the conventional and adjustable binders, respectively. Subsequent reduction of compression to more tolerable levels tended to worsen OH with both the conventional (-61mmHg; interquartile range, -33 to -80mmHg; P=.64) and adjustable (-67mmHg; interquartile range, -61 to -84mmHg; P=.79) binders. Subjects reported no differences in preferences between the binders in terms of preference or ease of use. CONCLUSIONS These results suggest that mild (10mmHg) abdominal compression prior to rising can ameliorate OH, but further compression once standing does not result in additional benefit.
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Affiliation(s)
- Juan J Figueroa
- Department of Neurology, Medical College of Wisconsin, Milwaukee, WI
| | | | | | - David M Sletten
- Department of Neurology, Medical College of Wisconsin, Milwaukee, WI
| | | | | | - Phillip Low
- Department of Neurology, Mayo Clinic, Rochester, MN
| | - Jeffrey R Basford
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN.
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108
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Chiang MC, Tseng MT, Pan CL, Chao CC, Hsieh ST. Progress in the treatment of small fiber peripheral neuropathy. Expert Rev Neurother 2015; 15:305-13. [PMID: 25664678 DOI: 10.1586/14737175.2015.1013097] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Small fiber neuropathy is a syndrome of diverse disease etiology because of multiple pathophysiologic mechanisms with major presentations of neuropathic pain and autonomic symptoms. Over the past decade, there has been substantial progress in the treatments for neuropathic pain, dysautonomia and disease-modifying strategy. In particular, anticonvulsants and antidepressants alleviate neuropathic pain based on randomized clinical trials.
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Affiliation(s)
- Ming-Chang Chiang
- Department of Biomedical Engineering, National Yang-Ming University, Taipei, Taiwan
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109
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Perez-Lloret S, Flabeau O, Fernagut PO, Pavy-Le Traon A, Rey MV, Foubert-Samier A, Tison F, Rascol O, Meissner WG. Current Concepts in the Treatment of Multiple System Atrophy. Mov Disord Clin Pract 2015; 2:6-16. [PMID: 30363880 DOI: 10.1002/mdc3.12145] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2014] [Revised: 12/13/2014] [Accepted: 12/18/2014] [Indexed: 12/21/2022] Open
Abstract
MSA is a progressive neurodegenerative disorder characterized by autonomic failure and a variable combination of poor levodopa-responsive parkinsonism and cerebellar ataxia (CA). Current therapeutic management is based on symptomatic treatment. Almost one third of MSA patients may benefit from l-dopa for the symptomatic treatment of parkinsonism, whereas physiotherapy remains the best therapeutic option for CA. Only midodrine and droxidopa were found to be efficient for neurogenic hypotension in double-blind, controlled studies, whereas other symptoms of autonomic failure may be managed with off-label treatments. To date, no curative treatment is available for MSA. Recent results of neuroprotective and -restorative trials have provided some hope for future advances. Considerations for future clinical trials are also discussed in this review.
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Affiliation(s)
- Santiago Perez-Lloret
- Laboratory of Epidemiology and Experimental Pharmacology Institute for Biomedical Research (BIOMED) School of Medical Sciences Pontifical Catholic University of Argentina (UCA) Buenos Aires Argentina.,The National Scientific and Technical Research Council (CONICET) Buenos Aires Argentina
| | - Olivier Flabeau
- Department of Neurology Center Hospitalier de la Côte Basque Bayonne France
| | - Pierre-Olivier Fernagut
- Institut des Maladies Neurodégénératives Université de Bordeaux Bordeaux France.,CNRS Institut des Maladies Neurodégénératives Bordeaux France
| | - Anne Pavy-Le Traon
- Departments of Clinical Pharmacology and Neurosciences University Hospital and University of Toulouse 3 Toulouse France.,French Reference Center for MSA Toulouse University Hospital Toulouse France
| | - María Verónica Rey
- Laboratory of Epidemiology and Experimental Pharmacology Institute for Biomedical Research (BIOMED) School of Medical Sciences Pontifical Catholic University of Argentina (UCA) Buenos Aires Argentina.,The National Scientific and Technical Research Council (CONICET) Buenos Aires Argentina
| | - Alexandra Foubert-Samier
- Institut des Maladies Neurodégénératives Université de Bordeaux Bordeaux France.,CNRS Institut des Maladies Neurodégénératives Bordeaux France.,French Reference Center for MSA Bordeaux University Hospital Bordeaux France
| | - Francois Tison
- Institut des Maladies Neurodégénératives Université de Bordeaux Bordeaux France.,CNRS Institut des Maladies Neurodégénératives Bordeaux France.,French Reference Center for MSA Bordeaux University Hospital Bordeaux France
| | - Olivier Rascol
- Departments of Clinical Pharmacology and Neurosciences University Hospital and University of Toulouse 3 Toulouse France.,French Reference Center for MSA Toulouse University Hospital Toulouse France
| | - Wassilios G Meissner
- Institut des Maladies Neurodégénératives Université de Bordeaux Bordeaux France.,CNRS Institut des Maladies Neurodégénératives Bordeaux France.,French Reference Center for MSA Bordeaux University Hospital Bordeaux France
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110
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Corrêa WG, Durand MT, Becari C, Tezini GC, do Carmo JM, de Oliveira M, Prado CM, Fazan R, Salgado HC. Pyridostigmine prevents haemodynamic alterations but does not affect their nycthemeral oscillations in infarcted mice. Auton Neurosci 2015; 187:50-5. [DOI: 10.1016/j.autneu.2014.11.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Revised: 10/10/2014] [Accepted: 11/09/2014] [Indexed: 12/20/2022]
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111
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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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112
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Ramirez CE, Okamoto LE, Arnold AC, Gamboa A, Diedrich A, Choi L, Raj SR, Robertson D, Biaggioni I, Shibao CA. Efficacy of atomoxetine versus midodrine for the treatment of orthostatic hypotension in autonomic failure. Hypertension 2014; 64:1235-40. [PMID: 25185131 PMCID: PMC4231172 DOI: 10.1161/hypertensionaha.114.04225] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2014] [Accepted: 08/11/2014] [Indexed: 01/27/2023]
Abstract
The clinical presentation of autonomic failure is orthostatic hypotension. Severely affected patients require pharmacological treatment to prevent presyncopal symptoms or frank syncope. We previously reported in a proof of concept study that pediatric doses of the norepinephrine transporter blockade, atomoxetine, increases blood pressure in autonomic failure patients with residual sympathetic activity compared with placebo. Given that the sympathetic nervous system is maximally activated in the upright position, we hypothesized that atomoxetine would be superior to midodrine, a direct vasoconstrictor, in improving upright blood pressure and orthostatic hypotension-related symptoms. To test this hypothesis, we compared the effect of acute atomoxetine versus midodrine on upright systolic blood pressure and orthostatic symptom scores in 65 patients with severe autonomic failure. There were no differences in seated systolic blood pressure (means difference=0.3 mm Hg; 95% confidence [CI], -7.3 to 7.9; P=0.94). In contrast, atomoxetine produced a greater pressor response in upright systolic blood pressure (means difference=7.5 mm Hg; 95% CI, 0.6 to 15; P=0.03) compared with midodrine. Furthermore, atomoxetine (means difference=0.4; 95% CI, 0.1 to 0.8; P=0.02), but not midodrine (means difference=0.5; 95% CI, -0.1 to 1.0; P=0.08), improved orthostatic hypotension-related symptoms as compared with placebo. The results of our study suggest that atomoxetine could be a superior therapeutic option than midodrine for the treatment of orthostatic hypotension in autonomic failure.
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Affiliation(s)
- Claudia E Ramirez
- From the Department of Medicine, Division of Clinical Pharmacology and the Autonomic Dysfunction Center, Vanderbilt University School of Medicine, Nashville, Tennessee (C.E.R., L.E.O., A.C.A., A.G., A.D., S.R.R., D.R., I.B., C.A.S.); and Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee (L.C.)
| | - Luis E Okamoto
- From the Department of Medicine, Division of Clinical Pharmacology and the Autonomic Dysfunction Center, Vanderbilt University School of Medicine, Nashville, Tennessee (C.E.R., L.E.O., A.C.A., A.G., A.D., S.R.R., D.R., I.B., C.A.S.); and Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee (L.C.)
| | - Amy C Arnold
- From the Department of Medicine, Division of Clinical Pharmacology and the Autonomic Dysfunction Center, Vanderbilt University School of Medicine, Nashville, Tennessee (C.E.R., L.E.O., A.C.A., A.G., A.D., S.R.R., D.R., I.B., C.A.S.); and Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee (L.C.)
| | - Alfredo Gamboa
- From the Department of Medicine, Division of Clinical Pharmacology and the Autonomic Dysfunction Center, Vanderbilt University School of Medicine, Nashville, Tennessee (C.E.R., L.E.O., A.C.A., A.G., A.D., S.R.R., D.R., I.B., C.A.S.); and Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee (L.C.)
| | - André Diedrich
- From the Department of Medicine, Division of Clinical Pharmacology and the Autonomic Dysfunction Center, Vanderbilt University School of Medicine, Nashville, Tennessee (C.E.R., L.E.O., A.C.A., A.G., A.D., S.R.R., D.R., I.B., C.A.S.); and Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee (L.C.)
| | - Leena Choi
- From the Department of Medicine, Division of Clinical Pharmacology and the Autonomic Dysfunction Center, Vanderbilt University School of Medicine, Nashville, Tennessee (C.E.R., L.E.O., A.C.A., A.G., A.D., S.R.R., D.R., I.B., C.A.S.); and Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee (L.C.)
| | - Satish R Raj
- From the Department of Medicine, Division of Clinical Pharmacology and the Autonomic Dysfunction Center, Vanderbilt University School of Medicine, Nashville, Tennessee (C.E.R., L.E.O., A.C.A., A.G., A.D., S.R.R., D.R., I.B., C.A.S.); and Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee (L.C.)
| | - David Robertson
- From the Department of Medicine, Division of Clinical Pharmacology and the Autonomic Dysfunction Center, Vanderbilt University School of Medicine, Nashville, Tennessee (C.E.R., L.E.O., A.C.A., A.G., A.D., S.R.R., D.R., I.B., C.A.S.); and Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee (L.C.)
| | - Italo Biaggioni
- From the Department of Medicine, Division of Clinical Pharmacology and the Autonomic Dysfunction Center, Vanderbilt University School of Medicine, Nashville, Tennessee (C.E.R., L.E.O., A.C.A., A.G., A.D., S.R.R., D.R., I.B., C.A.S.); and Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee (L.C.)
| | - Cyndya A Shibao
- From the Department of Medicine, Division of Clinical Pharmacology and the Autonomic Dysfunction Center, Vanderbilt University School of Medicine, Nashville, Tennessee (C.E.R., L.E.O., A.C.A., A.G., A.D., S.R.R., D.R., I.B., C.A.S.); and Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee (L.C.).
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113
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Abstract
Neurogenic orthostatic hypotension (NOH) is a debilitating condition associated with many central and peripheral neurological disorders. It has a complex pathophysiology and variable clinical presentation, which makes diagnosis and treatment difficult. Neurogenic orthostatic hypotension is often confused with other disorders of orthostatic intolerance, hypovolemic states and systemic conditions. Diagnosis is usually made by an autonomic specialist following characteristic responses to head-up tilt. Symptom control can be achieved through a combination of patient education, nonpharmacologic and pharmacologic therapy. The purpose of this review is to provide the clinician with a practical approach to the diagnosis and management of NOH.
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114
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The presence of dysautonomia in different subgroups of myasthenia gravis patients. J Neurol 2014; 261:2119-27. [DOI: 10.1007/s00415-014-7465-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Revised: 08/05/2014] [Accepted: 08/05/2014] [Indexed: 10/24/2022]
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115
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Charnogursky GA, Emanuele NV, Emanuele MA. Neurologic Complications of Diabetes. Curr Neurol Neurosci Rep 2014; 14:457. [DOI: 10.1007/s11910-014-0457-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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116
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Abstract
Neuropathies related to diabetes mellitus can affect 60-70% of patients with diabetes. These can include peripheral polyneuropathies, mononeuropathies, and autonomic neuropathies. Control of glucose, lipids, and hypertension and cessation of smoking can limit onset and progression of these neuropathies. Besides control of the above listed risk factors, we do not have effective medications to treat the pathophysiologic mechanisms of diabetic neuropathies. Treatment is limited to ameliorating pain and correcting the end organ consequences of the neuropathic processes.
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Affiliation(s)
- Gerald Charnogursky
- Division of Endocrinology and Metabolism, Loyola University Chicago, Stritch School of Medicine, Maywood, IL, USA.
| | - Hong Lee
- Division of Endocrinology and Metabolism, Loyola University Chicago, Stritch School of Medicine, Maywood, IL, USA
| | - Norma Lopez
- Division of Endocrinology and Metabolism, Loyola University Chicago, Stritch School of Medicine, Maywood, IL, USA
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117
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118
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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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119
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Perez-Lloret S, Rey MV, Pavy-Le Traon A, Rascol O. Droxidopa for the treatment of neurogenic orthostatic hypotension and other symptoms of neurodegenerative disorders. Expert Opin Orphan Drugs 2014. [DOI: 10.1517/21678707.2014.901167] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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120
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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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121
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Management of neurogenic orthostatic hypotension. J Am Med Dir Assoc 2014; 15:234-9. [PMID: 24388946 DOI: 10.1016/j.jamda.2013.10.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2013] [Revised: 10/25/2013] [Accepted: 10/25/2013] [Indexed: 11/20/2022]
Abstract
The burden of orthostatic hypotension (OH) on public health is a universally recognized enigmatic clinical condition that is associated with significant increases on morbidity and mortality rates, and can take a major toll on one's quality of life. Orthostatic hypotension is predictive of vascular deaths from acute myocardial infarction, strokes in the middle aged population, and increases mortality rates when associated with diabetes, hypertension, Parkinson's disease, and patients receiving renal dialysis. The consensus definition for OH is a fall in systolic blood pressure of at least 20 mm Hg and/or diastolic blood pressure of at least 10 mm Hg within 3 minutes of quiet standing. Because neurogenic OH is often accompanied by supine hypertension, the treatment program should aim toward minimizing OH and the potential fall injuries related to cerebral hypoperfusion without exacerbating nocturnal hypertension that may lead to excessive cardiovascular complications.
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122
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Perez-Lloret S, Rey MV, Pavy-Le Traon A, Rascol O. Orthostatic hypotension in Parkinson’s disease. Neurodegener Dis Manag 2013. [DOI: 10.2217/nmt.13.30] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
SUMMARY Orthostatic hypotension (OH) is a frequent non-motor symptom in Parkinson’s disease (PD), affecting between 22.9 and 38.4% of patients. In PD, OH is related to an increased risk of falls, and possibly to cognitive dysfunction and increased mortality. These data emphasize the importance of its prompt recognition and treatment. OH is related to pre- and post-ganglionic adrenergic denervation, but other factors, such as drugs, heat, meals or alcohol intake, might also induce or aggravate it. Evidence about the efficacy and safety of pharmacological or nonpharmacological strategies for OH treatment in PD is weak. Nonpharmacological measures include liberal addition of salt to the diet, exercise, compression stockings or physical maneuvers. Severe cases may be treated with midodrine or fludrocortisone. Some results suggest that droxidopa and fipamezole may be effective treatments. We finish this review article by discussing the most important unanswered questions about PD-related OH, which may be the focus of future research.
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Affiliation(s)
- Santiago Perez-Lloret
- Clinical Pharmacology & Epidemiology Laboratory, Pontifical Catholic University, Buenos Aires, Argentina
- Departments of Clinical Pharmacology & Neurosciences, & Clinical Investigation Center CIC9302, Institut National de la Santé & de la Recherche Médicale & University Hospital, University of Toulouse III, 37 Allées Jules Guesde, 31000, Toulouse, France
| | - María Verónica Rey
- Departments of Clinical Pharmacology & Neurosciences, & Clinical Investigation Center CIC9302, Institut National de la Santé & de la Recherche Médicale & University Hospital, University of Toulouse III, 37 Allées Jules Guesde, 31000, Toulouse, France
- Clinical Pharmacology & Epidemiology Laboratory, Pontifical Catholic University, Buenos Aires, Argentina
| | - Anne Pavy-Le Traon
- Departments of Clinical Pharmacology & Neurosciences, & Clinical Investigation Center CIC9302, Institut National de la Santé & de la Recherche Médicale & University Hospital, University of Toulouse III, 37 Allées Jules Guesde, 31000, Toulouse, France
| | - Olivier Rascol
- Departments of Clinical Pharmacology & Neurosciences, & Clinical Investigation Center CIC9302, Institut National de la Santé & de la Recherche Médicale & University Hospital, University of Toulouse III, 37 Allées Jules Guesde, 31000, Toulouse, France
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Ong ACL, Myint PK, Shepstone L, Potter JF. A systematic review of the pharmacological management of orthostatic hypotension. Int J Clin Pract 2013; 67:633-46. [PMID: 23758443 DOI: 10.1111/ijcp.12122] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2012] [Accepted: 12/27/2012] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVES The 'short' and 'long-term' benefits of pharmacological interventions to treat orthostatic hypotension (OH) remain unclear. The aim was to systematically examine the published literature on the effectiveness of different drug regimens for the treatment of OH. DESIGN Systematic review. SETTING MEDLINE (1950-Week 7, 2011), EMBASE (1980-Week 7, 2011), CINAHL (1981-Week 7, 2011) databases and hand-searching of bibliographies were used to identify suitable papers. PARTICIPANTS Studies selected were those, which investigated drug treatment of OH in a single- or double-blind randomised controlled trial (RCT) in humans over 18 years of age. MEASUREMENTS Data were extracted from suitable full-text articles by three investigators independently. RESULTS The 13 trials met the criteria for systematic review amongst which was considerable variation in the size of postural blood pressure (BP) change with active treatment. However, there was evidence that commonly used drugs midodrine or fludrocortisone therapy did increase standing or head-up-tilt (HUT) systolic blood pressure in certain patient groups. CONCLUSION The evidence that pharmacological therapy is of benefit for the treatment of OH is limited by the lack of good quality clinical trial evidence. Further well-designed RCTs of pharmacological treatment of OH investigating the impact on postural symptoms as well as actual BP changes are needed.
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Affiliation(s)
- A C L Ong
- Academic Department of Medicine for the Elderly, Norfolk and Norwich University Hospital, Norwich, UK.
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Sánchez-Ferro A, Benito-León J, Gómez-Esteban JC. The management of orthostatic hypotension in Parkinson's disease. Front Neurol 2013; 4:64. [PMID: 23772219 PMCID: PMC3677136 DOI: 10.3389/fneur.2013.00064] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2013] [Accepted: 05/19/2013] [Indexed: 12/23/2022] Open
Abstract
Orthostatic hypotension (OH) is a common and disabling symptom affecting Parkinson's disease (PD) patients. We present the effect of the different therapies commonly used to manage PD on this clinical manifestation. For this purpose, we describe the relationship between OH and the current treatments employed in PD, such as L-DOPA, dopaminergic agonists, and continuous dopaminergic stimulation therapies. Additionally, we review the therapeutic measures that could be used to ameliorate OH. There are different approaches to deal with this manifestation, including pharmacological and non-pharmacological treatments, although none of them is specifically aimed for treating OH in PD.
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Affiliation(s)
- Alvaro Sánchez-Ferro
- Department of Neurology, University Hospital "12 de Octubre," Madrid , Spain ; Department of Medicine, Faculty of Medicine, Complutense University , Madrid , Spain ; Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas , Madrid , Spain ; Instituto de Salud Carlos III , Madrid , Spain
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125
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Affiliation(s)
- Shin C. Beh
- Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, 5323, Harry Hines Blvd, Dallas, TX 75390, USA
| | - Benjamin M. Greenberg
- Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, 5323, Harry Hines Blvd, Dallas, TX 75390, USA
| | - Teresa Frohman
- Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, 5323, Harry Hines Blvd, Dallas, TX 75390, USA
| | - Elliot M. Frohman
- Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, 5323, Harry Hines Blvd, Dallas, TX 75390, USA
- Department of Ophthalmology, University of Texas Southwestern Medical Center, 5323, Harry Hines Blvd, Dallas, TX 75390, USA
- Corresponding author. Multiple Sclerosis Clinical Care Center, UT Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75235.
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Abstract
A syncope evaluation should start by identifying potentially life-threatening causes, including valvular heart disease, cardiomyopathies, and arrhythmias. Most patients who present with syncope, however, have the more benign vasovagal (reflex) syncope. A busy syncope practice often also sees patients with neurogenic orthostatic hypotension presenting with syncope or severe recurrent presyncope. Recognition of these potential confounders of syncope might be difficult without adequate knowledge of their presentation, and this can adversely affect optimal management. This article reviews the presentation of the vasovagal syncope confounder and the putative pathophysiology of orthostatic hypotension, and suggests options for nonpharmacologic and pharmacologic management.
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127
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Medical therapy and physical maneuvers in the treatment of the vasovagal syncope and orthostatic hypotension. Prog Cardiovasc Dis 2013; 55:425-33. [PMID: 23472781 DOI: 10.1016/j.pcad.2012.11.004] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Patients with vasovagal syncope and neurogenic orthostatic hypotension can both present with pre-syncope and syncope resulting from systemic hypotension. While not directly responsible for increased mortality, both of these conditions can have a tremendous deleterious impact on the daily lives of patients. This negative impact can take the form of both physical symptoms and injury, but also a psychological impact from living in fear of the next syncopal episode. Despite these similarities, these are different disorders with fixed damage to the autonomic nerves in neurogenic orthostatic hypotension, as opposed to a transient reflex hypotension in "neurally mediated" vasovagal syncope. The treatment approaches for both disorders are parallel. The first step is to educate the patient about the pathophysiology and prognosis of their disorder. Next, offending medications should be withdrawn when possible. Non-pharmacological therapies and maneuvers can be used, both in an effort to prevent the symptoms and to prevent syncope at the onset of presyncope. This is all that is required in many patients with vasovagal syncope. If needed, pharmacological options are also available for both vasovagal syncope and neurogenic orthostatic hypotension, many of which are focused on blood volume expansion, increasing cardiac venous return, or pressor agents to increase vascular tone. There is a paucity of high-quality clinical trial data to support the use of these pharmacological agents. We aim to review the literature on these different therapy choices and to give recommendations on tailored approaches to the treatment of these conditions.
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128
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Smith ND. Orthostatic Hypotension in the Patient with Diabetes: A Broad Review of Pharmacologic Treatment Options. J Pharm Technol 2013. [DOI: 10.1177/875512251302900105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective:To provide an evidence-based broad review of the pharmacologic management of orthostatic hypotension (OH) in the patient with diabetes.Data Sources:A search of PubMed, MD Consult, International Pharmaceutical Abstracts, and the Cochrane Register of Clinical Trials and Systematic Reviews was performed using the key words diabetes, autonomic neuropathy, orthostatic hypotension, midodrine, fludrocortisone, pyridostigmine, xamoterol, octreotide, pindolol, dihydroergotamine, erythropoietin, clonidine, acarbose, desmopressin, and droxidopa. Literature published between 1976 and August 2012 was included.Study Selection and Data Extraction:All articles in English and studies in humans including clinical trials, meta-analyses, practice guidelines, randomized controlled trials, and review articles were identified and evaluated. Studies not including patients with diabetes were excluded. The selection of materials was focused on those that would aid the pharmacist in caring for patients with orthostatic hypotension resulting from diabetic neuropathy.Data Synthesis:Definitive guidelines on the pharmacologic management of OH in the patient with diabetes are not available and recommendations must be assessed from available evidence-based sources. Ten trials of medications used in the patient with diabetes were assessed for efficacy and safety. From these trials, evidence-based therapy options were recommended. If nonpharmacologic measures are insufficient in ameliorating symptoms, fludrocortisone or midodrine should be considered as first-line agents in the absence of contraindications. Pyridostigmine, octreotide, or recombinant erythropoietin may be useful as adjunct or alternative agents. Combination therapy may be considered, based on coexisting conditions or response. When recommending both nonpharmacologic and pharmacologic therapy, careful attention should be paid to comorbid conditions such as congestive heart failure, supine hypertension, and kidney disease.Conclusions:There is insufficient evidence to recommend the routine use of medications other than the first-line agents fludrocortisone or midodrine in this patient population. Further trials with existing and new therapeutic options in patients with diabetes are warranted.
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Affiliation(s)
- Nicole D Smith
- NICOLE D SMITH BSPharm PharmD BCPS, at time of writing, PharmD Student, University of Florida, Gainesville, FL; now, Staff Pharmacist, East Liverpool City Hospital/River Valley Health Partners, East Liverpool, OH
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129
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Metzler M, Duerr S, Granata R, Krismer F, Robertson D, Wenning GK. Neurogenic orthostatic hypotension: pathophysiology, evaluation, and management. J Neurol 2012. [PMID: 23180176 PMCID: PMC3764319 DOI: 10.1007/s00415-012-6736-7] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Neurogenic orthostatic hypotension is a distinctive and treatable sign of cardiovascular autonomic dysfunction. It is caused by failure of noradrenergic neurotransmission that is associated with a range of primary or secondary autonomic disorders, including pure autonomic failure, Parkinson’s disease with autonomic failure, multiple system atrophy as well as diabetic and nondiabetic autonomic neuropathies. Neurogenic orthostatic hypotension is commonly accompanied by autonomic dysregulation involving other organ systems such as the bowel and the bladder. In the present review, we provide an overview of the clinical presentation, pathophysiology, epidemiology, evaluation and management of neurogenic orthostatic hypotension focusing on neurodegenerative disorders.
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Affiliation(s)
- Manuela Metzler
- Autonomic Function Laboratory, Division of Neurobiology, Department of Neurology, Innsbruck Medical University, Anichstrasse 35, Innsbruck, Austria
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130
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Logan IC, Witham MD. Efficacy of treatments for orthostatic hypotension: a systematic review. Age Ageing 2012; 41:587-94. [PMID: 22591985 DOI: 10.1093/ageing/afs061] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND orthostatic hypotension (OH) affects up to 30% of adults over 65 and frequently contributes to falls and syncopal episodes. Current guidelines suggest a wide range of treatments, but systematic reviews of the evidence base for such recommendations are lacking. METHODS we performed a systematic review to assess the evidence for all non-pharmacological and pharmacological interventions for OH. Our search included the following databases: MEDLINE; EMBASE; CINAHL; and the Cochrane library. We searched grey literature and references from included studies and other reviews. We included randomised, placebo-controlled trials, which measured postural drop as an outcome. Study quality was assessed using pre-specified measures of bias. RESULTS overall, 36 trials (21 interventions) were included. We identified a heterogeneous population and a wide variety of study methods, precluding meta-analysis. Most trials were of poor quality with high risk of bias. Changes in postural drop and symptoms were frequently inconsistent. Compression bandages, indomethacin, oxilofrine, potassium chloride and yohimbine improved the postural drop. Several vasoactive drugs-including midodrine and pyridostigmine-improved the standing blood pressure, but overall worsened the postural drop. CONCLUSIONS many commonly recommended interventions for OH have a limited evidence base supporting their use. High quality, randomised, controlled trials are needed to underpin clinical practice for this condition.
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Affiliation(s)
- Ian C Logan
- Medicine for the Elderly, NHS Tayside, Ninewells Hospital, Dundee DD1 9SY, UK.
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131
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Dispenzieri A, Gertz MA, Buadi F. What do I need to know about immunoglobulin light chain (AL) amyloidosis? Blood Rev 2012; 26:137-54. [PMID: 22537397 DOI: 10.1016/j.blre.2012.03.001] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Immunoglobulin light chain (AL) amyloidosis is the most common acquired systemic amyloidoses. Its presentation is often insidious and progressive, which may delay diagnosis. The interval between first symptoms and actual diagnosis along the intrinsic heterogeneity of tissue tropism create a wide spectrum of presentations, both in terms of scope and depth of symptoms and signs and functional status of patients. In this review, the authors review the pathogenesis, diagnosis and differential diagnosis of AL amyloidosis along with the prognosis and state-of-the-art management for patients with this affliction.
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132
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Abstract
The term "neurocardiology" refers to physiologic and pathophysiological interplays of the nervous and cardiovascular systems. This selective review provides an update about cardiovascular therapeutic implications of neurocardiology, with emphasis on disorders involving primary or secondary abnormalities of catecholamine systems. Concepts of scientific integrative medicine help understand these disorders. Scientific integrative medicine is not a treatment method or discipline but a way of thinking that applies systems concepts to acute and chronic disorders of regulation. Some of these concepts include stability by negative feedback regulation, multiple effectors, effector sharing, instability by positive feedback loops, allostasis, and allostatic load. Scientific integrative medicine builds on systems biology but is also distinct in several ways. A large variety of drugs and non-drug treatments are now available or under study for neurocardiologic disorders in which catecholamine systems are hyperfunctional or hypofunctional. The future of therapeutics in neurocardiology is not so much in new curative drugs as in applying scientific integrative medical ideas that take into account concurrent chronic degenerative disorders and interactions of multiple drug and non-drug treatments with each other and with those disorders.
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Affiliation(s)
- David S Goldstein
- Clinical Neurocardiology Section, Clinical Neurosciences Program, Division of Intramural Research, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD 20892, USA.
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133
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Flabeau O, Meissner WG, Tison F. Multiple system atrophy: current and future approaches to management. Ther Adv Neurol Disord 2011; 3:249-63. [PMID: 21179616 DOI: 10.1177/1756285610375328] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Multiple system atrophy (MSA) is a rare neurodegenerative disorder without any effective treatment in slowing or stopping disease progression. It is characterized by poor levodopa responsive Parkinsonism, cerebellar ataxia, pyramidal signs and autonomic failure in any combination. Current therapeutic strategies are primarily based on dopamine replacement and improvement of autonomic failure. However, symptomatic management remains disappointing and no curative treatment is yet available. Recent experimental evidence has confirmed the key role of alpha-synuclein aggregation in the pathogenesis of MSA. Referring to this hypothesis, transgenic and toxic animal models have been developed to assess candidate drugs for MSA. The standardization of diagnosis criteria and assessment procedures will allow large multicentre clinical trials to be conducted. In this article we review the available symptomatic treatment, recent results of studies investigating potential neuroprotective drugs, and future approaches for the management in MSA.
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Affiliation(s)
- Olivier Flabeau
- Department of Neurology, University Hospital of Bordeaux, Bordeaux, France
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134
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Abstract
OPINION STATEMENT Dementia in Parkinson's disease encompasses a spectrum relating to motor, psychiatric, and cognitive symptoms that are classified as either Dementia with Lewy Bodies (DLB) (initial cognitive symptoms) or Parkinson's Disease Dementia (PDD) (initial motor signs preceding cognitive symptoms by at least a year). Anticholinergic and antipsychotic drugs have a high risk of adverse cognitive and/or motor effects, so their use should be minimized or avoided. Neuroleptic sensitivity is a severe psychomotor adverse reaction that is particularly associated with potent dopamine-blocking agents such as haloperidol. It occurs in up to 50% of individuals with PDD or DLB. Mild psychotic symptoms should first be addressed by reducing anticholinergic and/or dopaminergic agents, if possible. Patients with psychotic symptoms that threaten the safety of the patient or caregiver may benefit from treatment with quetiapine or, in refractory cases, clozapine. Cholinesterase inhibitors as a drug class have been shown to have beneficial effects on cognition in DLB and PDD, and may help to alleviate some psychiatric symptoms, such as apathy, anxiety, hallucinations, and delusions. Memantine may help to moderate cognitive symptoms in DLB and PDD, although current data suggest a more variable response, particularly in PDD. Parkinsonian motor signs that are accompanied by clinically significant cognitive impairment should be treated with carbidopa/levodopa only, as dopamine agonists and other antiparkinsonian medications generally carry a higher risk of provoking or exacerbating psychotic symptoms. Excessive daytime sleepiness and REM sleep behavior disorder are common associated features of PDD and DLB. Minimizing sedating medications during the day and promoting nocturnal sleep may help the daytime sleepiness; melatonin, clonazepam, gabapentin, and possibly memantine may be useful in treating REM sleep behavior disorder. Orthostatic hypotension can be managed with various nonpharmacologic interventions, and if needed, fludrocortisone and pyridostigmine. Midodrine should be used cautiously, if at all.
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Affiliation(s)
- Avrom L Kurtz
- Department of Neurology, CB 7025, The University of North Carolina at Chapel Hill, 3129 Physician Office Building, Chapel Hill, NC, 27599, USA,
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135
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Park A, Stacy M. Dopamine-induced nonmotor symptoms of Parkinson's disease. PARKINSONS DISEASE 2011; 2011:485063. [PMID: 21603184 PMCID: PMC3096061 DOI: 10.4061/2011/485063] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/15/2010] [Accepted: 02/14/2011] [Indexed: 12/19/2022]
Abstract
Nonmotor symptoms of Parkinson's disease (PD) may emerge secondary to the underlying pathogenesis of the disease, while others are recognized side effects of treatment. Inevitably, there is an overlap as the disease advances and patients require higher dosages and more complex medical regimens. The non-motor symptoms that emerge secondary to dopaminergic therapy encompass several domains, including neuropsychiatric, autonomic, and sleep. These are detailed in the paper. Neuropsychiatric complications include hallucinations and psychosis. In addition, compulsive behaviors, such as pathological gambling, hypersexuality, shopping, binge eating, and punding, have been shown to have a clear association with dopaminergic medications. Dopamine dysregulation syndrome (DDS) is a compulsive behavior that is typically viewed through the lens of addiction, with patients needing escalating dosages of dopamine replacement therapy. Treatment side effects on the autonomic system include nausea, orthostatic hypotension, and constipation. Sleep disturbances include fragmented sleep, nighttime sleep problems, daytime sleepiness, and sleep attacks. Recognizing the non-motor symptoms that can arise specifically from dopamine therapy is useful to help optimize treatment regimens for this complex disease.
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Affiliation(s)
- Ariane Park
- Department of Neurology, The Ohio State University, Columbus, OH 43210, USA
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136
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KANJWAL KHALIL, KARABIN BEVERLY, SHEIKH MUJEEB, ELMER LAWRENCE, KANJWAL YOUSUF, SAEED BILAL, GRUBB BLAIRP. Pyridostigmine in the Treatment of Postural Orthostatic Tachycardia: A Single-Center Experience. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2011; 34:750-5. [DOI: 10.1111/j.1540-8159.2011.03047.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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137
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Autoimmune autonomic ganglionopathy after a CNS infection. Clin Auton Res 2011; 21:171-2. [PMID: 21210293 DOI: 10.1007/s10286-010-0108-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2010] [Accepted: 11/30/2010] [Indexed: 10/18/2022]
Abstract
We report the first Greek case of autoimmune autonomic ganglionopathy seropositive for antibodies against ganglionic acetylcholine receptors, unique for an antecedent viral cerebellitis and long, slowly progressive course, with improvement after treatment with pyridostigmine.
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138
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Aminoff MJ, Christine CW, Friedman JH, Chou KL, Lyons KE, Pahwa R, Bloem BR, Parashos SA, Price CC, Malaty IA, Iansek R, Bodis-Wollner I, Suchowersky O, Oertel WH, Zamudio J, Oberdorf J, Schmidt P, Okun MS. Management of the hospitalized patient with Parkinson's disease: current state of the field and need for guidelines. Parkinsonism Relat Disord 2010; 17:139-45. [PMID: 21159538 DOI: 10.1016/j.parkreldis.2010.11.009] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2010] [Revised: 11/05/2010] [Accepted: 11/09/2010] [Indexed: 01/05/2023]
Abstract
OBJECTIVE To review the literature and to identify practice gaps in the management of the hospitalized Parkinson's disease (PD) patient. BACKGROUND Patients with PD are admitted to hospitals at higher rates, and frequently have longer hospital stays than the general population. Little is known about outpatient interventions that might reduce the need for hospitalization and also reduce hospital-related complications. METHODS A literature review was performed on PubMed about hospitalization and PD between 1970 and 2010. In addition, in press peer-reviewed papers or published abstracts known to the authors were included. Information was reviewed by a National Parkinson Foundation workgroup and a narrative review article was generated. RESULTS Motor disturbances in PD are believed to be a causal factor in the higher rates of admissions and complications. However, other conditions are commonly recorded as the primary reason for hospitalization including motor complications, reduced mobility, lack of compliance, inappropriate use of neuroleptics, falls, fractures, pneumonia, and other important medical problems. There are many relevant issues related to hospitalization in PD. Medications, dosages and specific dosage schedules are critical. Staff training regarding medications and medication management may help to avoid complications, particularly those related to reduced mobility, and aspiration pneumonia. Treatment of infections and a return to early mobility is also critical to management. CONCLUSIONS Educational programs, recommendations, and guidelines are needed to better train interdisciplinary teams in the management of the PD patient. These initiatives have the potential for both cost savings and improved outcomes from a preventative and a hospital management standpoint.
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Affiliation(s)
- Michael J Aminoff
- National Parkinson Foundation Center of Excellence, University of California San Francisco, Neurology Department, CA, USA
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Ceravolo R, Rossi C, Kiferle L, Bonuccelli U. Nonmotor symptoms in Parkinson’s disease: the dark side of the moon. FUTURE NEUROLOGY 2010. [DOI: 10.2217/fnl.10.69] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Nonmotor symptoms may appear during the course of Parkinson’s disease, complicating the advanced phase in particular, but are also common in the premotor phase of Parkinson’s disease. The appearance of nonmotor manifestations represents a milestone, determining a worse prognosis and lower quality of life; however, they are often misdiagnosed and untreated. The spectrum of nonmotor symptoms encompasses mood disorders, psychosis, dementia, sleep disorders, impulse-control disorders and autonomic dysfunctions. This article describes these nonmotor symptoms and their management.
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Affiliation(s)
- Roberto Ceravolo
- Department of Neurosciences, Section of Neurology, University of Pisa, via Roma 67, 56126 Pisa, Italy
| | - Carlo Rossi
- Department of Neurosciences, Section of Neurology, University of Pisa, via Roma 67, 56126 Pisa, Italy
| | - Lorenzo Kiferle
- Department of Neurosciences, Section of Neurology, University of Pisa, via Roma 67, 56126 Pisa, Italy
| | - Ubaldo Bonuccelli
- Department of Neurosciences, Section of Neurology, University of Pisa, via Roma 67, 56126 Pisa, Italy
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Abstract
SummaryThe autonomic nervous system comprises the sympathetic, parasympathetic and enteric nervous systems and plays an integral role in homeostasis. This includes cardiovascular and temperature control, glucose metabolism, gastrointestinal and reproductive function and increasing evidence to support its involvement in the inflammatory response to infection and cancer. Ageing is associated with autonomic dysfunction, and many clinical syndromes associated with older adults are due to inadequate autonomic responses to physiological stressors. The aim of this review is to explore the relationship between autonomic dysfunction and ageing illustrated with examples of maladaptive autonomic responses in a variety of different clinical syndromes including an exploration of autonomic cellular changes. Appropriate investigation and management strategies are outlined, recognizing the fine balance needed to improve symptoms without creating further medical complications.
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141
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Jordan J. What rare autonomic disorders can teach us about human cardiovascular pharmacology. Hypertension 2010; 56:811-3. [PMID: 20837880 DOI: 10.1161/hypertensionaha.110.157966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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142
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Shibao C, Okamoto LE, Gamboa A, Yu C, Diedrich A, Raj SR, Robertson D, Biaggioni I. Comparative efficacy of yohimbine against pyridostigmine for the treatment of orthostatic hypotension in autonomic failure. Hypertension 2010; 56:847-51. [PMID: 20837887 DOI: 10.1161/hypertensionaha.110.154898] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Orthostatic hypotension affects patients with autonomic failure producing considerable disability because of presyncopal symptoms. Severely affected patients may have residual sympathetic tone that can be engaged to increase blood pressure (BP) with the α-2 adrenergic antagonist yohimbine. This medication activates sympathetic outflow centrally and unrestrains norepinephrine release from noradrenergic neurons. Alternatively, the acetylcholinesterase inhibitor, pyridostigmine, can increase sympathetic tone by improving ganglionic cholinergic neurotransmission. Our purpose was to compare these complementary approaches and to explore whether the combination would lead to synergistic increases in BP. We compared the effects of 60 mg of pyridostigmine and 5.4 mg of yohimbine in a single-blind, randomized, placebo-controlled, crossover fashion. In a subset of patients we tested the combination of pyridostigmine and yohimbine. Our primary outcome was the change in standing diastolic BP 60 minutes after drug administration from baseline. We studied a total of 31 patients with severe autonomic failure. Yohimbine significantly improved standing diastolic BP as compared with placebo (11±3 mm Hg [95% CI: 6 to 16 mm Hg]; P<0.001). On the contrary, pyridostigmine did not increase the standing diastolic BP (0.6±3 mm Hg [95% CI: -5 to 5 mm Hg]; P=0.823). Only yohimbine showed a significant improvement in presyncopal symptoms. Sixteen patients received the combination of pyridostigmine and yohimbine, but no evidence of synergistic pressor effect was found. Engaging residual sympathetic tone with yohimbine is a more effective approach to improve orthostatic hypotension as compared with pyridostigmine in patients with severe orthostatic hypotension.
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Affiliation(s)
- Cyndya Shibao
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tenn, USA
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143
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Figueroa JJ, Basford JR, Low PA. Preventing and treating orthostatic hypotension: As easy as A, B, C. Cleve Clin J Med 2010; 77:298-306. [PMID: 20439562 DOI: 10.3949/ccjm.77a.09118] [Citation(s) in RCA: 99] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Orthostatic hypotension is a chronic, debilitating illness that is difficult to treat. The therapeutic goal is to improve postural symptoms, standing time, and function rather than to achieve upright normotension, which can lead to supine hypertension. Drug therapy alone is never adequate. Because orthostatic stress varies with circumstances during the day, a patient-oriented approach that emphasizes education and nonpharmacologic strategies is critical. We provide easy-to-remember management recommendations, using a combination of drug and nondrug treatments that have proven efficacious.
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Affiliation(s)
- Juan J Figueroa
- Department of Neurology, Mayo Clinic, Rochester, MN 55905, USA
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144
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Affiliation(s)
- Rodica Pop-Busui
- Department of Internal Medicine, Division of Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, Michigan, USA.
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145
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Tolosa E, Santamaria J, Gaig C, Compta Y. Nonmotor Aspects of Parkinson's Disease. MOVEMENT DISORDERS 4 2010. [DOI: 10.1016/b978-1-4160-6641-5.00014-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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146
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Abstract
Sudden falling with loss of consciousness from syncope and symptoms of orthostatic intolerance are common, dramatic clinical problems of diverse cause, but cerebral hypoperfusion is the ultimate mechanism in most. Cardiac, reflex, and orthostatic hypotension are important forms to consider. Syncope must be differentiated from seizures, psychiatric events, drop attacks, and other mimics. However, factors such as syncopal induced movements, ictal bradycardia, and insufficient clinical information can confound accurate diagnosis and hamper appropriate treatment. Progress in the diagnosis, treatment, and understanding of underlying mechanisms is continually advancing.
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Affiliation(s)
- Louis H Weimer
- The Neurological Institute of New York, New York, NY 10032, USA.
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147
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Abstract
Parkinson's disease (PD) is the second most common neurodegenerative disease after Alzheimer's disease. Traditionally, attention has focused on the motor symptomatology of PD, but it is now appreciated that the nonmotor symptoms affecting neuropsychiatric, sleep, autonomic, and sensory domains occur in up to 88% of PD patients and can be an important source of disability. Nonmotor manifestations of PD play a significant role in the impairment of disease-related quality of life. The cause of nonmotor manifestations of PD is multifactorial, but to a large extent, these manifestations are related to the nature of the neurodegenerative process and the widespread nondopaminergic neuropathological changes associated with the disease. Recognition of nonmotor disability is essential not only for ascertaining the functional status of patients but also for better appreciating the nature of the neurodegenerative process in PD. In addition, a number of nonmotor manifestations can precede the onset of motor symptoms in PD and can be used as screening tools allowing for early disease identification and for trials of possible disease-modifying interventions. This article reviews depression, sleep, and autonomic dysfunction in PD.
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Affiliation(s)
- Tanya Simuni
- Department of Neurology, Northwestern University, Chicago, IL, USA.
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148
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Treatment of supine hypertension in autonomic failure with gastrostomy feeding at night. Auton Neurosci 2008; 143:77-8. [DOI: 10.1016/j.autneu.2008.06.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2008] [Revised: 06/16/2008] [Accepted: 06/18/2008] [Indexed: 11/21/2022]
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149
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Grubb BP, Kanjwal Y, Karabin B, Imran N. Orthostatic Hypotension and Autonomic Failure: A Concise Guide to Diagnosis and Management. Clin Med Cardiol 2008. [DOI: 10.4137/cmc.s926] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Blair P. Grubb
- Electrophysiology Section, Division of Cardiovascular Medicine, Health Science Campus, University of Toledo, Toledo, Ohio U.S.A
| | - Yousuf Kanjwal
- Electrophysiology Section, Division of Cardiovascular Medicine, Health Science Campus, University of Toledo, Toledo, Ohio U.S.A
| | - Beverly Karabin
- Electrophysiology Section, Division of Cardiovascular Medicine, Health Science Campus, University of Toledo, Toledo, Ohio U.S.A
| | - Nasar Imran
- Electrophysiology Section, Division of Cardiovascular Medicine, Health Science Campus, University of Toledo, Toledo, Ohio U.S.A
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150
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Abstract
Orthostatic hypotension (OH) is common in elderly people and in patients with disorders such as diabetes and Parkinson's disease. Grading of the severity of OH and its effect on the patient's quality of life are important. The symptoms vary with orthostatic stress, and subtle symptoms such as tiredness and cognitive impairment should be recognised. Standard drug treatment for OH is effective but worsens supine hypertension, whereas pyridostigmine can improve OH slightly but significantly without worsening of supine hypertension. Because orthostatic stress varies from moment to moment and drug treatment is suboptimal, drug treatment of OH needs to be combined with non-pharmacological approaches, such as compression of venous capacitance beds, use of physical counter-manoeuvres, and intermittent water-bolus treatment.
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Affiliation(s)
- Phillip A Low
- Department of Neurology, Mayo Clinic Rochester, MN 55905, USA.
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