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González-Duarte A, Cotrina-Vidal M, Kaufmann H, Norcliffe-Kaufmann L. Familial dysautonomia. Clin Auton Res 2023; 33:269-280. [PMID: 37204536 DOI: 10.1007/s10286-023-00941-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Accepted: 03/30/2023] [Indexed: 05/20/2023]
Abstract
Familial dysautonomia (FD) is an autosomal recessive hereditary sensory and autonomic neuropathy (HSAN, type 3) expressed at birth with profound sensory loss and early death. The FD founder mutation in the ELP1 gene arose within the Ashkenazi Jews in the sixteenth century and is present in 1:30 Jews of European ancestry. The mutation yield a tissue-specific skipping of exon 20 and a loss of function of the elongator-1 protein (ELP1), which is essential for the development and survival of neurons. Patients with FD produce variable amounts of ELP1 in different tissues, with the brain producing mostly mutant transcripts. Patients have excessive blood pressure variability due to the failure of the IXth and Xth cranial nerves to carry baroreceptor signals. Neurogenic dysphagia causes frequent aspiration leading to chronic pulmonary disease. Characteristic hyperadrenergic "autonomic crises" consisting of brisk episodes of severe hypertension, tachycardia, skin blotching, retching, and vomiting occur in all patients. Progressive features of the disease include retinal nerve fiber loss and blindness, and proprioceptive ataxia with severe gait impairment. Chemoreflex failure may explain the high frequency of sudden death in sleep. Although 99.5% of patients are homozygous for the founder mutation, phenotypic severity varies, suggesting that modifier genes impact expression. Medical management is currently symptomatic and preventive. Disease-modifying therapies are close to clinical testing. Endpoints to measure efficacy have been developed, and the ELP1 levels are a good surrogate endpoint for target engagement. Early intervention may be critical for treatment to be successful.
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Affiliation(s)
- Alejandra González-Duarte
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, New York, NY, USA.
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, CdMx, México.
| | - Maria Cotrina-Vidal
- Department of Neurology, Stroke Division. New York University School of Medicine, New York, NY, USA
| | - Horacio Kaufmann
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, New York, NY, USA
| | - Lucy Norcliffe-Kaufmann
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, New York, NY, USA
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2
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Ramprasad C, Palma JA, Norcliffe-Kaufmann L, Levy J, Chen LA, Kaufmann H. Gastrointestinal bleeding in children with familial dysautonomia: a case-control study. Clin Auton Res 2023; 33:87-92. [PMID: 36735101 DOI: 10.1007/s10286-023-00925-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 01/16/2023] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Familial dysautonomia (FD) is a rare inherited autosomal recessive disorder with abnormal somatosensory, enteric, and afferent autonomic neurons. We aimed to define the incidence of gastrointestinal bleeding and its associated risk factors in patients with FD. METHODS In this retrospective case-control study, we identified all episodes of gastrointestinal bleeding in patients with FD, occurring over four decades (January 1980-December 2017), using the New York University FD registry. RESULTS We identified 104 episodes of gastrointestinal bleeding occurring in 60 patients with FD. The estimated incidence rate of gastrointestinal bleeds in the FD population rate was 4.20 episodes per 1000 person-years. We compared the 60 cases with 94 age-matched controls. Bleeding in the upper gastrointestinal tract from gastric and duodenal ulcers occurred most frequently (64 bleeds, 75.6%). Patients were more likely to have a gastrostomy (G)-tube and a Nissen fundoplication [odds ratio (OR) 3.73, 95% confidence interval (CI) 1.303-13.565] than controls. The mean time from G-tube placement to first gastrointestinal bleed was 7.01 years. The mean time from Nissen fundoplication to bleed was 7.01 years. Cases and controls had similar frequency of intake of nonsteroidal antiinflammatory drugs (NSAID) and selective serotonin reuptake inhibitors (SSRI). CONCLUSION The incidence of gastrointestinal bleeding in the pediatric FD population was estimated to be 4.20 per 1000 person-years, 21 times higher than in the general pediatric population (0.2 per 1000 person-years). Patients with FD with a G-tube and a Nissen fundoplication had a higher risk of a subsequent gastrointestinal bleeding.
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Affiliation(s)
- Chethan Ramprasad
- Division of Gastroenterology and Hepatology, Department of Medicine, New York University Grossman School of Medicine, New York City, NY, USA
- Division of Gastroenterology, University of Pennsylvania, Philadelphia, PA, USA
| | - Jose-Alberto Palma
- Department of Neurology, Dysautonomia Center, New York University Grossman School of Medicine, 530 First Av, Suite 9Q, New York City, NY, 10016, USA
| | - Lucy Norcliffe-Kaufmann
- Department of Neurology, Dysautonomia Center, New York University Grossman School of Medicine, 530 First Av, Suite 9Q, New York City, NY, 10016, USA
| | - Joseph Levy
- Division of Pediatric Gastroenterology, New York University Grossman School of Medicine, New York City, NY, USA
| | - Lea Ann Chen
- Division of Gastroenterology and Hepatology, Department of Medicine, New York University Grossman School of Medicine, New York City, NY, USA
- Division of Gastroenterology and Hepatology, Rutgers University, Robert Wood Johnson School of Medicine, New Brunswick, NJ, USA
| | - Horacio Kaufmann
- Department of Neurology, Dysautonomia Center, New York University Grossman School of Medicine, 530 First Av, Suite 9Q, New York City, NY, 10016, USA.
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3
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Wu HF, Yu W, Saito-Diaz K, Huang CW, Carey J, Lefcort F, Hart GW, Liu HX, Zeltner N. Norepinephrine transporter defects lead to sympathetic hyperactivity in Familial Dysautonomia models. Nat Commun 2022; 13:7032. [PMID: 36396637 PMCID: PMC9671909 DOI: 10.1038/s41467-022-34811-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 11/08/2022] [Indexed: 11/19/2022] Open
Abstract
Familial dysautonomia (FD), a rare neurodevelopmental and neurodegenerative disorder affects the sympathetic and sensory nervous system. Although almost all patients harbor a mutation in ELP1, it remains unresolved exactly how function of sympathetic neurons (symNs) is affected; knowledge critical for understanding debilitating disease hallmarks, including cardiovascular instability or dysautonomic crises, that result from dysregulated sympathetic activity. Here, we employ the human pluripotent stem cell (hPSC) system to understand symN disease mechanisms and test candidate drugs. FD symNs are intrinsically hyperactive in vitro, in cardiomyocyte co-cultures, and in animal models. We report reduced norepinephrine transporter expression, decreased intracellular norepinephrine (NE), decreased NE re-uptake, and excessive extracellular NE in FD symNs. SymN hyperactivity is not a direct ELP1 mutation result, but may connect to NET via RAB proteins. We found that candidate drugs lowered hyperactivity independent of ELP1 modulation. Our findings may have implications for other symN disorders and may allow future drug testing and discovery.
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Affiliation(s)
- Hsueh-Fu Wu
- Center for Molecular Medicine, University of Georgia, Athens, GA, USA
- Department of Biochemistry and Molecular Biology, University of Georgia, Athens, GA, USA
| | - Wenxin Yu
- Regenerative Bioscience Center, Department of Animal and Dairy Science, College of Agricultural and Environmental Sciences, University of Georgia, Athens, GA, USA
| | - Kenyi Saito-Diaz
- Center for Molecular Medicine, University of Georgia, Athens, GA, USA
| | - Chia-Wei Huang
- Department of Biochemistry and Molecular Biology, University of Georgia, Athens, GA, USA
- Complex Carbohydrate Research Center, University of Georgia, Athens, GA, USA
| | - Joseph Carey
- Department of Microbiology and Cell Biology, Montana State University, Bozeman, MT, USA
| | - Frances Lefcort
- Department of Microbiology and Cell Biology, Montana State University, Bozeman, MT, USA
| | - Gerald W Hart
- Department of Biochemistry and Molecular Biology, University of Georgia, Athens, GA, USA
- Complex Carbohydrate Research Center, University of Georgia, Athens, GA, USA
| | - Hong-Xiang Liu
- Regenerative Bioscience Center, Department of Animal and Dairy Science, College of Agricultural and Environmental Sciences, University of Georgia, Athens, GA, USA
| | - Nadja Zeltner
- Center for Molecular Medicine, University of Georgia, Athens, GA, USA.
- Department of Biochemistry and Molecular Biology, University of Georgia, Athens, GA, USA.
- Department of Cellular Biology, University of Georgia, Athens, GA, USA.
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4
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Orthostatic hypotension with nondipping: phenotype of neurodegenerative disease. Hypertens Res 2022; 45:1514-1516. [PMID: 35836000 DOI: 10.1038/s41440-022-00980-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Accepted: 06/12/2022] [Indexed: 11/08/2022]
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5
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Norcliffe-Kaufmann L. Stress and the baroreflex. Auton Neurosci 2022; 238:102946. [PMID: 35086020 DOI: 10.1016/j.autneu.2022.102946] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 11/16/2021] [Accepted: 01/16/2022] [Indexed: 11/27/2022]
Abstract
The stress response to emotions elicits the release of glucocorticoids from the adrenal cortex, epinephrine from the adrenal medulla, and norepinephrine from the sympathetic nerves. The baroreflex adapts to buffer these responses to ensure that perfusion to the organs meets the demands while maintaining blood pressure within a within a narrow range. While stressor-evoked autonomic cardiovascular responses may be adaptive for the short-term, the recurrent exaggerated cardiovascular stress reactions can be maladaptive in the long-term. Prolonged stress or loss of the baroreflex's buffering capacity can predispose episodes of heightened sympathetic activity during stress leading to hypertension, tachycardia, and ventricular wall motion abnormalities. This review discusses 1) how the baroreflex responds to acute and chronic stressors, 2) how lesions in the neuronal pathways of the baroreflex alter the ability to respond or counteract the stress response, and 3) the techniques to assess baroreflex sensitivity and stress responses. Evidence suggests that loss of baroreflex sensitivity may predispose heightened autonomic responses to stress and at least in part explain the association between stress, mortality and cardiovascular diseases.
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周 政, 吴 牡, 李 维, 艾 金, 张 晓, 陈 玉, 宋 业, 王 芳, 沈 阳, 谭 国. [Baroreceptor failure syndrome after head and neck tumor surgery]. LIN CHUANG ER BI YAN HOU TOU JING WAI KE ZA ZHI = JOURNAL OF CLINICAL OTORHINOLARYNGOLOGY, HEAD, AND NECK SURGERY 2021; 35:1052-1056. [PMID: 34886615 PMCID: PMC10128367 DOI: 10.13201/j.issn.2096-7993.2021.11.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Indexed: 04/30/2023]
Abstract
With the continuous updating of head and neck surgery concepts and techniques, more and more head and neck surgeries are developing in the direction of refinement.however, the more complete the surgery, the greater the possibility of subsequent nerve exposure and injury. Even a slight perturbation of the nerve may cause serious complications, such as pressure receptor failure.It is necessary to review the mechanisms and the characteristics of baroreceptor failure syndrome after head and neck tumor surgery.
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Affiliation(s)
- 政 周
- 中南大学湘雅三医院耳鼻咽喉头颈外科(长沙,410005)
| | - 牡丽 吴
- 中南大学湘雅三医院耳鼻咽喉头颈外科(长沙,410005)
| | - 维 李
- 中南大学湘雅三医院耳鼻咽喉头颈外科(长沙,410005)
| | - 金刚 艾
- 中南大学湘雅三医院耳鼻咽喉头颈外科(长沙,410005)
| | - 晓伟 张
- 中南大学湘雅三医院耳鼻咽喉头颈外科(长沙,410005)
| | - 玉 陈
- 中南大学湘雅三医院耳鼻咽喉头颈外科(长沙,410005)
| | - 业勋 宋
- 中南大学湘雅三医院耳鼻咽喉头颈外科(长沙,410005)
| | - 芳 王
- 中南大学湘雅三医院耳鼻咽喉头颈外科(长沙,410005)
| | - 阳 沈
- 中南大学湘雅三医院耳鼻咽喉头颈外科(长沙,410005)
| | - 国林 谭
- 中南大学湘雅三医院耳鼻咽喉头颈外科(长沙,410005)
- 谭国林,
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7
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Norcliffe-Kaufmann L, Millar Vernetti P, Palma JA, Balgobin BJ, Kaufmann H. Afferent Baroreflex Dysfunction: Decreased or Excessive Signaling Results in Distinct Phenotypes. Semin Neurol 2020; 40:540-549. [PMID: 32906172 DOI: 10.1055/s-0040-1713892] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Head and neck tumors can affect afferent baroreceptor neurons and either interrupt or intermittently increase their signaling, causing blood pressure to become erratic. When the afferent fibers of the baroreflex are injured by surgery or radiotherapy or fail to develop as in familial dysautonomia, their sensory information is no longer present to regulate arterial blood pressure, resulting in afferent baroreflex failure. When the baroreflex afferents are abnormally activated, such as by paragangliomas in the neck, presumably by direct compression, they trigger acute hypotension and bradycardia and frequently syncope, by a mechanism similar to the carotid sinus syndrome. We describe our observations in a large series of 23 patients with afferent baroreflex dysfunction and the cardiovascular autonomic features that arise when the sensory baroreceptor neurons are injured or compressed. The management of afferent baroreceptor dysfunction is limited, but pharmacological strategies can mitigate blood pressure swings, improve symptoms, and may reduce hypertensive organ damage. Although rare, the prevalence of afferent baroreflex dysfunction appears to be increasing in middle-aged men due to human papillomavirus related oropharyngeal cancer.
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Affiliation(s)
| | | | - Jose-Alberto Palma
- Department of Neurology, New York University School of Medicine, New York, New York
| | - Bhumika J Balgobin
- Department of Neurology, New York University School of Medicine, New York, New York
| | - Horacio Kaufmann
- Department of Neurology, New York University School of Medicine, New York, New York
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8
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Norcliffe-Kaufmann L, Palma JA, Martinez J, Kaufmann H. Carbidopa for Afferent Baroreflex Failure in Familial Dysautonomia: A Double-Blind Randomized Crossover Clinical Trial. Hypertension 2020; 76:724-731. [PMID: 32654554 DOI: 10.1161/hypertensionaha.120.15267] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Afferent lesions of the arterial baroreflex occur in familial dysautonomia. This leads to excessive blood pressure variability with falls and frequent surges that damage the organs. These hypertensive surges are the result of excess peripheral catecholamine release and have no adequate treatment. Carbidopa is a selective DOPA-decarboxylase inhibitor that suppresses catecholamines production outside the brain. To learn whether carbidopa can inhibit catecholamine-induced hypertensive surges in patients with severe afferent baroreflex failure, we conducted a double-blind randomized crossover trial in which patients with familial dysautonomia received high dose carbidopa (600 mg/day), low-dose carbidopa (300 mg/day), or matching placebo in 3 4-week treatment periods. Among the 22 patients enrolled (13 females/8 males), the median age was 26 (range, 12-59 years). At enrollment, patients had hypertensive peaks to 164/116 (range, 144/92 to 213/150 mm Hg). Twenty-four hour urinary norepinephrine excretion, a marker of peripheral catecholamine release, was significantly suppressed on both high dose and low dose carbidopa, compared with placebo (P=0.0075). The 2 co-primary end points of the trial were met. The SD of systolic BP variability was reduced at both carbidopa doses (low dose: 17±4; high dose: 18±5 mm Hg) compared with placebo (23±7 mm Hg; P=0.0013), and there was a significant reduction in the systolic BP peaks on active treatment (P=0.0015). High- and low-dose carbidopa were similarly effective and well tolerated. This study provides class Ib evidence that carbidopa can reduce blood pressure variability in patients with congenital afferent baroreflex failure. Similar beneficial effects are observed in patients with acquired baroreflex lesions.
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Affiliation(s)
- Lucy Norcliffe-Kaufmann
- From the Department of Neurology, NYU Dysautonomia Center, New York University School of Medicine
| | - Jose-Alberto Palma
- From the Department of Neurology, NYU Dysautonomia Center, New York University School of Medicine
| | - Jose Martinez
- From the Department of Neurology, NYU Dysautonomia Center, New York University School of Medicine
| | - Horacio Kaufmann
- From the Department of Neurology, NYU Dysautonomia Center, New York University School of Medicine
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9
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Biaggioni I, Shibao CA, Diedrich A, Muldowney JAS, Laffer CL, Jordan J. Blood Pressure Management in Afferent Baroreflex Failure: JACC Review Topic of the Week. J Am Coll Cardiol 2020; 74:2939-2947. [PMID: 31806138 DOI: 10.1016/j.jacc.2019.10.027] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 10/18/2019] [Accepted: 10/21/2019] [Indexed: 12/14/2022]
Abstract
Afferent baroreflex failure is most often due to damage of the carotid sinus nerve because of neck surgery or radiation. The clinical picture is characterized by extreme blood pressure lability with severe hypertensive crises, hypotensive episodes, and orthostatic hypotension, making it the most difficult form of hypertension to manage. There is little evidence-based data to guide treatment. Recommendations rely on understanding the underlying pathophysiology, relevant clinical pharmacology, and anecdotal experience. The goal of treatment should be improving quality of life rather than normalization of blood pressure, which is rarely achievable. Long-acting central sympatholytic drugs are the mainstay of treatment, used at the lowest doses that prevent the largest hypertensive surges. Short-acting clonidine should be avoided because of rebound hypertension, but can be added to control residual hypertensive episodes, often triggered by mental stress or exertion. Hypotensive episodes can be managed with countermeasures and short-acting pressor agents if necessary.
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Affiliation(s)
- Italo Biaggioni
- Division of Clinical Pharmacology, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Pharmacology, Vanderbilt University Medical Center, Nashville, Tennessee; Vanderbilt Autonomic Dysfunction Center, Nashville, Tennessee.
| | - Cyndya A Shibao
- Division of Clinical Pharmacology, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee; Vanderbilt Autonomic Dysfunction Center, Nashville, Tennessee
| | - André Diedrich
- Division of Clinical Pharmacology, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee; Vanderbilt Autonomic Dysfunction Center, Nashville, Tennessee
| | - James A S Muldowney
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee; Vanderbilt Autonomic Dysfunction Center, Nashville, Tennessee; Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Cheryl L Laffer
- Division of Clinical Pharmacology, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jens Jordan
- Institute of Aerospace Medicine, German Aerospace Center, Cologne, Germany; Aerospace Medicine, University of Cologne, Cologne, Germany
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10
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11
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Palma JA, Gileles-Hillel A, Norcliffe-Kaufmann L, Kaufmann H. Chemoreflex failure and sleep-disordered breathing in familial dysautonomia: Implications for sudden death during sleep. Auton Neurosci 2019; 218:10-15. [PMID: 30890343 DOI: 10.1016/j.autneu.2019.02.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 02/11/2019] [Indexed: 01/04/2023]
Abstract
Familial dysautonomia (Riley-Day syndrome, hereditary sensory and autonomic neuropathy type III) is a rare autosomal recessive disease characterized by impaired development of primary sensory and autonomic neurons resulting in a severe neurological phenotype, which includes arterial baroreflex and chemoreflex failure with high frequency of sleep-disordered breathing and sudden death during sleep. Although a rare disease, familial dysautonomia represents a unique template to study the interactions between sleep-disordered breathing and abnormal chemo- and baroreflex function. In patients with familial dysautonomia, ventilatory responses to hypercapnia are reduced, and to hypoxia are almost absent. In response to hypoxia, these patients develop paradoxical hypoventilation, hypotension, bradycardia, and potentially, death. Impaired ventilatory control due to chemoreflex failure acquires special relevance during sleep when conscious control of respiration withdraws. Overall, almost all adult (85%) and pediatric (95%) patients have some degree of sleep-disordered breathing. Obstructive apnea events are more frequent in adults, whereas central apnea events are more severe and frequent in children. The annual incidence rate of sudden death during sleep in patients with familial dysautonomia is 3.4 per 1000 person-year, compared to 0.5-1 per 1000 person-year of sudden unexpected death in epilepsy. This review summarizes recent developments in the understanding of sleep-disordered breathing in patients with familial dysautonomia, the risk factors for sudden death during sleep, and the specific interventions that could prevent it.
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Affiliation(s)
- Jose-Alberto Palma
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, New York, NY, United States of America
| | - Alex Gileles-Hillel
- Departments of Pediatrics, Pediatric Pulmonology and Sleep, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Lucy Norcliffe-Kaufmann
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, New York, NY, United States of America
| | - Horacio Kaufmann
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, New York, NY, United States of America.
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12
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Kazachkov M, Palma JA, Norcliffe-Kaufmann L, Bar-Aluma BE, Spalink CL, Barnes EP, Amoroso NE, Balou SM, Bess S, Chopra A, Condos R, Efrati O, Fitzgerald K, Fridman D, Goldenberg RM, Goldhaber A, Kaufman DA, Kothare SV, Levine J, Levy J, Lubinsky AS, Maayan C, Moy LC, Rivera PJ, Rodriguez AJ, Sokol G, Sloane MF, Tan T, Kaufmann H. Respiratory care in familial dysautonomia: Systematic review and expert consensus recommendations. Respir Med 2018; 141:37-46. [PMID: 30053970 PMCID: PMC6084453 DOI: 10.1016/j.rmed.2018.06.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 05/14/2018] [Accepted: 06/18/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Familial dysautonomia (Riley-Day syndrome, hereditary sensory autonomic neuropathy type-III) is a rare genetic disease caused by impaired development of sensory and afferent autonomic nerves. As a consequence, patients develop neurogenic dysphagia with frequent aspiration, chronic lung disease, and chemoreflex failure leading to severe sleep disordered breathing. The purpose of these guidelines is to provide recommendations for the diagnosis and treatment of respiratory disorders in familial dysautonomia. METHODS We performed a systematic review to summarize the evidence related to our questions. When evidence was not sufficient, we used data from the New York University Familial Dysautonomia Patient Registry, a database containing ongoing prospective comprehensive clinical data from 670 cases. The evidence was summarized and discussed by a multidisciplinary panel of experts. Evidence-based and expert recommendations were then formulated, written, and graded using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system. RESULTS Recommendations were formulated for or against specific diagnostic tests and clinical interventions. Diagnostic tests reviewed included radiological evaluation, dysphagia evaluation, gastroesophageal evaluation, bronchoscopy and bronchoalveolar lavage, pulmonary function tests, laryngoscopy and polysomnography. Clinical interventions and therapies reviewed included prevention and management of aspiration, airway mucus clearance and chest physical therapy, viral respiratory infections, precautions during high altitude or air-flight travel, non-invasive ventilation during sleep, antibiotic therapy, steroid therapy, oxygen therapy, gastrostomy tube placement, Nissen fundoplication surgery, scoliosis surgery, tracheostomy and lung lobectomy. CONCLUSIONS Expert recommendations for the diagnosis and management of respiratory disease in patients with familial dysautonomia are provided. Frequent reassessment and updating will be needed.
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Affiliation(s)
- Mikhail Kazachkov
- Department of Pediatric Pulmonology, New York University School of Medicine, New York, NY, United States; Gastroesophageal, Upper Airway and Respiratory Diseases Center, New York University School of Medicine, New York, NY, United States
| | - Jose-Alberto Palma
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, New York, NY, United States
| | - Lucy Norcliffe-Kaufmann
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, New York, NY, United States
| | - Bat-El Bar-Aluma
- Pediatric Pulmonary Unit, The Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Israel
| | - Christy L Spalink
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, New York, NY, United States
| | - Erin P Barnes
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, New York, NY, United States
| | - Nancy E Amoroso
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine. New York University School of Medicine, New York, NY, United States
| | - Stamatela M Balou
- Department of Otolaryngology-Head and Neck Surgery, New York University School of Medicine, New York, NY, United States
| | - Shay Bess
- Department of Orthopedic Surgery, New York University School of Medicine, New York, NY, United States
| | - Arun Chopra
- Department of Pediatrics, Division of Pediatric Critical Care, New York University School of Medicine, New York, NY, United States
| | - Rany Condos
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine. New York University School of Medicine, New York, NY, United States
| | - Ori Efrati
- Pediatric Pulmonary Unit, The Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Israel
| | - Kathryn Fitzgerald
- Department of Pediatric Pulmonology, New York University School of Medicine, New York, NY, United States
| | - David Fridman
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine. New York University School of Medicine, New York, NY, United States
| | - Ronald M Goldenberg
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine. New York University School of Medicine, New York, NY, United States
| | - Ayelet Goldhaber
- Department of Pediatrics, Pediatric Gastroenterology Unit, New York University School of Medicine, New York, NY, United States
| | - David A Kaufman
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine. New York University School of Medicine, New York, NY, United States
| | - Sanjeev V Kothare
- Department of Neurology, Pediatric Sleep Medicine Unit, New York University School of Medicine, New York, NY, United States
| | - Jeremiah Levine
- Department of Pediatrics, Pediatric Gastroenterology Unit, New York University School of Medicine, New York, NY, United States
| | - Joseph Levy
- Department of Pediatrics, Pediatric Gastroenterology Unit, New York University School of Medicine, New York, NY, United States
| | - Anthony S Lubinsky
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine. New York University School of Medicine, New York, NY, United States
| | - Channa Maayan
- Department of Pediatrics. Hebrew University-Hadassah Medical School, Jerusalem, Israel
| | - Libia C Moy
- Department of Pediatrics, Pediatric Gastroenterology Unit, New York University School of Medicine, New York, NY, United States
| | - Pedro J Rivera
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine. New York University School of Medicine, New York, NY, United States
| | - Alcibiades J Rodriguez
- Department of Neurology, Sleep Laboratory, New York University School of Medicine, New York, NY, United States
| | - Gil Sokol
- Pediatric Pulmonary Unit, The Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Israel
| | - Mark F Sloane
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine. New York University School of Medicine, New York, NY, United States
| | - Tina Tan
- Gastroesophageal, Upper Airway and Respiratory Diseases Center, New York University School of Medicine, New York, NY, United States
| | - Horacio Kaufmann
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, New York, NY, United States.
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13
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Singh K, Palma JA, Kaufmann H, Tkachenko N, Norcliffe-Kaufmann L, Spalink C, Kazachkov M, Kothare SV. Prevalence and characteristics of sleep-disordered breathing in familial dysautonomia. Sleep Med 2018; 45:33-38. [PMID: 29680425 PMCID: PMC5918267 DOI: 10.1016/j.sleep.2017.12.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Accepted: 12/30/2017] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Familial dysautonomia (FD) is an autosomal recessive disorder characterized by impaired development of sensory and afferent autonomic nerves. Untreated sleep-disordered breathing (SDB) has been reported to increase the risk of sudden unexpected death in FD. We aimed to describe the prevalence and characteristics of SDB in FD. PATIENTS/METHODS Seventy-five patients with FD (20 adults and 55 children) underwent in-lab polysomnography, including peripheral capillary oxygen saturation (SpO2) and end-tidal capnography (EtCO2) measurements. A t-test and Spearman's correlation analysis were performed to evaluate the impact of age on sleep, occurrence of apneas, SpO2 and EtCO2 levels; and to determine the relationship between apneas and SpO2/EtCO2 measurements during different sleep stages. RESULTS Overall, 85% of adults and 91% of pediatric patients had some degree of SDB. Obstructive sleep apneas were more severe in adults (8.5 events/h in adults vs. 3.5 events/h in children, p = 0.04), whereas central apneas were more severe (10.8 vs. 2.8 events/h, p = 0.04) and frequent (61.8% vs. 45%, p = 0.017) in children. Overall, a higher apnea-hypopnea index was associated with increased severity of hypoxia and hypoventilation, although in a significant fraction of patients (67% and 46%), hypoxemia and hypoventilation occurred independent of apneas. CONCLUSION Most adult and pediatric patients with FD suffer from some degree of SDB. There was a differential effect of age in the pattern of SDB observed. In some FD patients, hypoventilation and hypoxia occurred independently of apneas. Therefore, we recommend including EtCO2 monitoring during polysomnography in all patients with FD to detect SDB.
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Affiliation(s)
- Kanwaljit Singh
- University of Massachusetts Medical School, Worcester, MA, USA
| | - Jose-Alberto Palma
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, New York, NY, USA
| | - Horacio Kaufmann
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, New York, NY, USA
| | - Nataliya Tkachenko
- Department of Pediatrics, New York University Langone Medical Center, New York, NY, USA
| | - Lucy Norcliffe-Kaufmann
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, New York, NY, USA
| | - Christy Spalink
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, New York, NY, USA
| | - Mikhail Kazachkov
- Department of Pediatrics, New York University Langone Medical Center, New York, NY, USA
| | - Sanjeev V Kothare
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, New York, NY, USA.
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14
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A Controlled Trial of Inhaled Bronchodilators in Familial Dysautonomia. Lung 2017; 196:93-101. [PMID: 29234869 DOI: 10.1007/s00408-017-0073-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2017] [Accepted: 10/06/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Chronic lung disease is a leading cause of premature death in patients with familial dysautonomia (FD). A significant number of patients have obstructive airway disease, yet it is not known whether this is pharmacologically reversible. METHODS We conducted a double-blind, placebo-controlled, randomized clinical trial comparing the beta 2 agonist albuterol with the muscarinic blocker ipratropium bromide in patients homozygous for the IKBKAP founder mutation. Albuterol, ipratropium bromide, and placebo were administered on 3 separate days via nebulizer in the seated position. Airway responsiveness was evaluated using spirometry and impulse oscillometry 30 min post dose. Cardiovascular effects were evaluated by continuous monitoring of blood pressure, RR intervals, cardiac output, and systemic vascular resistance. RESULTS A total of 14 patients completed the trial. Neither active agent had significant detrimental effects on heart rate or rhythm or blood pressure. Albuterol and ipratropium were similar in their bronchodilator effectiveness causing significant improvement in forced expiratory volume in 1-s (FEV1, p = 0.002 and p = 0.030). Impulse oscillometry measures were consistent with a reduction in total airway resistance post nebulization (resistance at 5 Hz p < 0.006). CONCLUSION Airway obstruction is pharmacologically reversible in a number of patients with FD. In the short term, both albuterol and ipratropium were well tolerated and not associated with major cardiovascular adverse events.
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15
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Palma JA, Norcliffe-Kaufmann L, Perez MA, Spalink CL, Kaufmann H. Sudden Unexpected Death During Sleep in Familial Dysautonomia: A Case-Control Study. Sleep 2017; 40:3831157. [PMID: 28521050 DOI: 10.1093/sleep/zsx083] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Study Objectives Sudden unexpected death during sleep (SUDS) is the most common cause of death in patients with familial dysautonomia (FD), an autosomal recessive disease characterized by sensory and autonomic dysfunction. It remains unknown what causes SUDS in these patients and who is at highest risk. We tested the hypothesis that SUDS in FD is linked to sleep-disordered breathing. Methods We retrospectively identified patients with FD who died suddenly and unexpectedly during sleep and had undergone polysomnography within the 18-month period before death. For each case, we sampled one age-matched surviving subject with FD that had also undergone polysomnography within the 18-month period before study. Data on polysomnography, EKG, ambulatory blood pressure monitoring, arterial blood gases, blood count, and metabolic panel were analyzed. Results Thirty-two deceased cases and 31 surviving controls were included. Autopsy was available in six cases. Compared with controls, participants with SUDS were more likely to be receiving treatment with fludrocortisone (odds ratio [OR]; 95% confidence interval) (OR 29.7; 4.1-213.4), have untreated obstructive sleep apnea (OR 17.4; 1.5-193), and plasma potassium levels <4 mEq/L (OR 19.5; 2.36-161) but less likely to use noninvasive ventilation at night (OR 0.19; 0.06-0.61). Conclusions Initiation of noninvasive ventilation when required and discontinuation of fludrocortisone treatment may reduce the high incidence rate of SUDS in patients with FD. Our findings contribute to the understanding of the link between autonomic, cardiovascular, and respiratory risk factors in SUDS.
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Affiliation(s)
- Jose-Alberto Palma
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, New York, NY
| | - Lucy Norcliffe-Kaufmann
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, New York, NY
| | - Miguel A Perez
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, New York, NY
| | - Christy L Spalink
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, New York, NY
| | - Horacio Kaufmann
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, New York, NY
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16
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Transcranial Doppler in autonomic testing: standards and clinical applications. Clin Auton Res 2017; 28:187-202. [PMID: 28821991 DOI: 10.1007/s10286-017-0454-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Accepted: 07/13/2017] [Indexed: 02/06/2023]
Abstract
When cerebral blood flow falls below a critical limit, syncope occurs and, if prolonged, ischemia leads to neuronal death. The cerebral circulation has its own complex finely tuned autoregulatory mechanisms to ensure blood supply to the brain can meet the high metabolic demands of the underlying neuronal tissue. This involves the interplay between myogenic and metabolic mechanisms, input from noradrenergic and cholinergic neurons, and the release of vasoactive substrates, including adenosine from astrocytes and nitric oxide from the endothelium. Transcranial Doppler (TCD) is a non-invasive technique that provides real-time measurements of cerebral blood flow velocity. TCD can be very useful in the work-up of a patient with recurrent syncope. Cerebral autoregulatory mechanisms help defend the brain against hypoperfusion when perfusion pressure falls on standing. Syncope occurs when hypotension is severe, and susceptibility increases with hyperventilation, hypocapnia, and cerebral vasoconstriction. Here we review clinical standards for the acquisition and analysis of TCD signals in the autonomic laboratory and the multiple methods available to assess cerebral autoregulation. We also describe the control of cerebral blood flow in autonomic disorders and functional syndromes.
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17
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Intranasal dexmedetomidine for adrenergic crisis in familial dysautonomia. Clin Auton Res 2017; 27:279-282. [PMID: 28674865 DOI: 10.1007/s10286-017-0442-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Accepted: 06/05/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE To report the use of intranasal dexmedetomidine, an α2-adrenergic agonist for the acute treatment of refractory adrenergic crisis in patients with familial dysautonomia. METHODS Case series. RESULTS Three patients with genetically confirmed familial dysautonomia (case 1: 20-year-old male; case 2: 43-year-old male; case 3: 26-year-old female) received intranasal dexmedetomidine 2 mcg/kg, half of the dose in each nostril, for the acute treatment of adrenergic crisis. Within 8-17 min of administering the intranasal dose, the adrenergic crisis symptoms abated, and blood pressure and heart rate returned to pre-crises values. Adrenergic crises eventually resumed, and all three patients required hospitalization for investigation of the cause of the crises. CONCLUSIONS Intranasal dexmedetomidine is a feasible and safe acute treatment for adrenergic crisis in patients with familial dysautonomia. Further controlled studies are required to confirm the safety and efficacy in this population.
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18
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Fuente Mora C, Palma JA, Kaufmann H, Norcliffe-Kaufmann L. Cerebral autoregulation and symptoms of orthostatic hypotension in familial dysautonomia. J Cereb Blood Flow Metab 2017; 37:2414-2422. [PMID: 27613312 PMCID: PMC5531340 DOI: 10.1177/0271678x16667524] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Familial dysautonomia is an inherited autonomic disorder with afferent baroreflex failure. We questioned why despite low blood pressure standing, surprisingly few familial dysautonomia patients complain of symptomatic hypotension or have syncope. Using transcranial Doppler ultrasonography of the middle cerebral artery, we measured flow velocity (mean, peak systolic, and diastolic), area under the curve, pulsatility index, and height of the dictrotic notch in 25 patients with familial dysautonomia and 15 controls. In patients, changing from sitting to a standing position, decreased BP from 124 ± 4/64 ± 3 to 82 ± 3/37 ± 2 mmHg (p < 0.0001, for both). Despite low BP, all patients denied orthostatic symptoms. Middle cerebral artery velocity fell minimally, and the magnitude of the reductions were similar to those observed in healthy controls, in whom BP upright did not fall. While standing, patients had a greater fall in cerebrovascular resistance (p < 0.0001), an increase in pulsatility (p < 0.0001), and a deepening of the dicrotic notch (p = 0.0010), findings all consistent with low cerebrovascular resistance. No significant changes occurred in controls. Patients born with baroreflex deafferentation retain the ability to buffer wide fluctuations in BP and auto-regulate cerebral blood flow. This explains how they can tolerate extremely low BPs standing that would otherwise induce syncope.
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Affiliation(s)
| | | | | | - Lucy Norcliffe-Kaufmann
- Lucy Norcliffe-Kaufmann, Department of Neurology, Dysautonomia Center, New York University School of Medicine, 530 First Avenue, Suite 9Q, New York, NY 10016, USA.
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19
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Dillon RC, Palma JA, Spalink CL, Altshuler D, Norcliffe-Kaufmann L, Fridman D, Papadopoulos J, Kaufmann H. Dexmedetomidine for refractory adrenergic crisis in familial dysautonomia. Clin Auton Res 2016; 27:7-15. [PMID: 27752785 DOI: 10.1007/s10286-016-0383-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2016] [Accepted: 09/27/2016] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Adrenergic crises are a cardinal feature of familial dysautonomia (FD). Traditionally, adrenergic crises have been treated with the sympatholytic agent clonidine or with benzodiazepines, which can cause excessive sedation and respiratory depression. Dexmedetomidine is a centrally-acting α 2-adrenergic agonist with greater selectivity and shorter half-life than clonidine. We evaluated the preliminary effectiveness and safety of intravenous dexmedetomidine in the treatment of refractory adrenergic crisis in patients with FD. METHODS Retrospective chart review of patients with genetically confirmed FD who received intravenous dexmedetomidine for refractory adrenergic crises. The primary outcome was preliminary effectiveness of dexmedetomidine defined as change in blood pressure (BP) and heart rate (HR) 1 h after the initiation of dexmedetomidine. Secondary outcomes included incidence of adverse events related to dexmedetomidine, hospital and intensive care unit (ICU) length of stay, and hemodynamic parameters 12 h after dexmedetomidine cessation. RESULTS Nine patients over 14 admissions were included in the final analysis. At 1 h after the initiation of dexmedetomidine, systolic BP decreased from 160 ± 7 to 122 ± 7 mmHg (p = 0.0005), diastolic BP decreased from 103 ± 6 to 65 ± 8 (p = 0.0003), and HR decreased from 112 ± 4 to 100 ± 5 bpm (p = 0.0047). The median total adverse events during dexmedetomidine infusion was 1 per admission. Median hospital length of stay was 9 days [interquartile range (IQR) 3-11 days] and median ICU length of stay was 7 days (IQR 3-11 days). CONCLUSIONS Intravenous dexmedetomidine is safe in patients with FD and appears to be effective to treat refractory adrenergic crisis. Dexmedetomidine may be considered in FD patients who do not respond to conventional clonidine and benzodiazepine pharmacotherapy.
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Affiliation(s)
- Ryan C Dillon
- Department of Pharmacy, NYU Langone Medical Center, New York, NY, USA
| | - Jose-Alberto Palma
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, 530 First Avenue Suite 9Q, New York, NY, 10016, USA
| | - Christy L Spalink
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, 530 First Avenue Suite 9Q, New York, NY, 10016, USA
| | - Diana Altshuler
- Department of Pharmacy, NYU Langone Medical Center, New York, NY, USA
| | - Lucy Norcliffe-Kaufmann
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, 530 First Avenue Suite 9Q, New York, NY, 10016, USA
| | - David Fridman
- Department of Medicine, NYU Langone Medical Center, New York, NY, USA
| | - John Papadopoulos
- Department of Pharmacy, NYU Langone Medical Center, New York, NY, USA
- Department of Medicine, NYU Langone Medical Center, New York, NY, USA
| | - Horacio Kaufmann
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, 530 First Avenue Suite 9Q, New York, NY, 10016, USA.
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