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Subbaiah MAM, Rautio J, Meanwell NA. Prodrugs as empowering tools in drug discovery and development: recent strategic applications of drug delivery solutions to mitigate challenges associated with lead compounds and drug candidates. Chem Soc Rev 2024; 53:2099-2210. [PMID: 38226865 DOI: 10.1039/d2cs00957a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2024]
Abstract
The delivery of a drug to a specific organ or tissue at an efficacious concentration is the pharmacokinetic (PK) hallmark of promoting effective pharmacological action at a target site with an acceptable safety profile. Sub-optimal pharmaceutical or ADME profiles of drug candidates, which can often be a function of inherently poor physicochemical properties, pose significant challenges to drug discovery and development teams and may contribute to high compound attrition rates. Medicinal chemists have exploited prodrugs as an informed strategy to productively enhance the profiles of new chemical entities by optimizing the physicochemical, biopharmaceutical, and pharmacokinetic properties as well as selectively delivering a molecule to the site of action as a means of addressing a range of limitations. While discovery scientists have traditionally employed prodrugs to improve solubility and membrane permeability, the growing sophistication of prodrug technologies has enabled a significant expansion of their scope and applications as an empowering tool to mitigate a broad range of drug delivery challenges. Prodrugs have emerged as successful solutions to resolve non-linear exposure, inadequate exposure to support toxicological studies, pH-dependent absorption, high pill burden, formulation challenges, lack of feasibility of developing solid and liquid dosage forms, first-pass metabolism, high dosing frequency translating to reduced patient compliance and poor site-specific drug delivery. During the period 2012-2022, the US Food and Drug Administration (FDA) approved 50 prodrugs, which amounts to 13% of approved small molecule drugs, reflecting both the importance and success of implementing prodrug approaches in the pursuit of developing safe and effective drugs to address unmet medical needs.
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Affiliation(s)
- Murugaiah A M Subbaiah
- Department of Medicinal Chemistry, Biocon Bristol Myers Squibb R&D Centre, Biocon Park, Bommasandra Phase IV, Bangalore, PIN 560099, India.
| | - Jarkko Rautio
- School of Pharmacy, University of Eastern Finland, Kuopio, Finland
| | - Nicholas A Meanwell
- The Baruch S. Blumberg Institute, Doylestown, PA 18902, USA
- Department of Medicinal Chemistry, The College of Pharmacy, The University of Michigan, Ann Arbor, MI 48109, USA
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Vidal-Petiot E, Pathak A, Azulay JP, Pavy-Le Traon A, Hanon O. Orthostatic hypotension: Review and expert position statement. Rev Neurol (Paris) 2024; 180:53-64. [PMID: 38123372 DOI: 10.1016/j.neurol.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 11/19/2023] [Accepted: 11/21/2023] [Indexed: 12/23/2023]
Abstract
Orthostatic hypotension is defined as a drop in systolic blood pressure of at least 20mmHg or a drop in diastolic blood pressure of at least 10mmHg within 3minutes of standing. It is a common disorder, especially in high-risk populations such as elderly subjects and patients with neurological diseases, and is associated with markedly increased morbidity and mortality. Its management can be challenging, particularly in cases where supine hypertension is associated with severe orthostatic hypotension. Education of the patient, non-pharmacological measures, and drug adaptation are the cornerstones of treatment. Pharmacological treatment should be individualized according to the severity, underlying cause, 24-hour blood pressure profile, and associated coexisting conditions. First-line therapies are midodrine and fludrocortisone, which may need to be combined for optimal care of severe cases.
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Affiliation(s)
- E Vidal-Petiot
- Service de physiologie, ESH Excellence Center, hôpital Bichat, Assistance Publique-Hôpitaux de Paris, 75018 Paris, France; INSERM U1148, Université Paris-Cité and Université Sorbonne Paris Nord, LVTS, 75018 Paris, France.
| | - A Pathak
- Service de cardiologie, ESH Excellence Center, centre hospitalier Princesse Grace, 1, avenue Pasteur, 98000 Monaco, France
| | - J-P Azulay
- Service de neurologie et pathologie du mouvement, hôpital de la Timone, 13385 Marseille cedex 05, France
| | - A Pavy-Le Traon
- Service de neurologie, CHU de Toulouse, 31059 Toulouse cedex, France; UMR 1297, institut des maladies métaboliques et cardiovasculaires, Toulouse, France
| | - O Hanon
- Service de gériatrie, université Paris-Cité, EA4468, hôpital Broca, AP-HP, 75013 Paris, France
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Wouda MF, Bengtson EI, Høyer E, Wesche AP, Jørgensen V. Acute orthostatic responses during early mobilisation of patients with acquired brain injury - Innowalk pro versus standing frame. J Rehabil Assist Technol Eng 2024; 11:20556683241240488. [PMID: 38737723 PMCID: PMC11088804 DOI: 10.1177/20556683241240488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 03/04/2024] [Indexed: 05/14/2024] Open
Abstract
Introduction Early mobilisation is paramount in the rehabilitation of patients with acquired brain injuries. However, the effectiveness of mobilisation to standing combined with passive leg movement in mitigating orthostatic intolerance remains uncertain. Hence, we investigated whether participants exhibited better tolerance standing in a motorized standing device with passive leg movements, Innowalk Pro, compared to a traditional standing frame. Methods 17 patients with acquired brain injury (<1 year post-injury) performed two sessions in each standing device on four separate days. Maximum standing time was 30 min, less when symptoms of syncope or volitional exhaustion occurred. Besides total standing time, electromyography of thigh muscles, and changes in mean arterial pressure and heart rate were monitored at rest and during standing. Results No significant differences were found in standing time, changes in mean arterial pressure or heart rate between standing in Innowalk Pro and the standing frame. However, participants had significantly more thigh muscle activation (p = 0.006) when standing in Innowalk Pro. Conclusions Mobilising participants with a subacute acquired brain injury in a standing frame with motorised passive movements of the lower limbs did, despite higher thigh muscle activation, not lead to better orthostatic tolerance or prolonged standing time compared to a traditional standing frame.
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Affiliation(s)
- Matthijs F Wouda
- Research Department, Sunnaas Rehabilitation Hospital, Nesoddtangen, Norway
- Oslo Metropolitan University, Oslo, Norway
| | - Espen I Bengtson
- Research Department, Sunnaas Rehabilitation Hospital, Nesoddtangen, Norway
| | - Ellen Høyer
- Research Department, Sunnaas Rehabilitation Hospital, Nesoddtangen, Norway
| | - Alhed P Wesche
- Research Department, Sunnaas Rehabilitation Hospital, Nesoddtangen, Norway
| | - Vivien Jørgensen
- Research Department, Sunnaas Rehabilitation Hospital, Nesoddtangen, Norway
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4
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Li Y, Lu D, Gong Y. Cobalt(II)-Catalyzed Selective Three-Component Oxyalkylation of N-Aryl Glycinates: A Route to CF 3-Labeled Threonine Analogues. J Org Chem 2023. [PMID: 38033236 DOI: 10.1021/acs.joc.3c01874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
Glycinates, protected enols, and an electrophilic trifluoromethylating reagent were employed to assemble CF3-labeled threonine analogues through a radical addition cascade. To suppress the competing oxidation of the oxyalkyl radical intermediate, various redox catalysts were evaluated and Co(II) exhibited supreme selectivity control with a proper counterion. A series of glycinate and related peptides were thus successfully modified under Co-catalysis. Mechanistic studies revealed that a N-aryl glycinate could be preferentially oxidized by cobalt over the oxyalkyl radical to generate an imine intermediate, and the key to this selectivity could be ascribed to the prechelation of glycinate, as well as a weakly basic carboxylate counterion.
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Affiliation(s)
- Yadong Li
- Hubei Key Laboratory of Bioinorganic Chemistry & Materia Medica, School of Chemistry and Chemical Engineering, Huazhong University of Science and Technology, 1037 Luoyu Road, Wuhan 430074, Hubei, China
| | - Dengfu Lu
- Hubei Key Laboratory of Bioinorganic Chemistry & Materia Medica, School of Chemistry and Chemical Engineering, Huazhong University of Science and Technology, 1037 Luoyu Road, Wuhan 430074, Hubei, China
- Research Institute of Huazhong University of Science and Technology in Shenzhen, 9 Yuexing Third Road, Shenzhen 518063, Guangdong, China
| | - Yuefa Gong
- Hubei Key Laboratory of Bioinorganic Chemistry & Materia Medica, School of Chemistry and Chemical Engineering, Huazhong University of Science and Technology, 1037 Luoyu Road, Wuhan 430074, Hubei, China
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Hoxhaj P, Shah S, Muyolema Arce VE, Khan W, Sadeghzadegan A, Singh S, Collado GF, Goyal A, Khawaja I, Botlaguduru D, Razzaq W, Abdin ZU, Gupta I. Ampreloxetine Versus Droxidopa in Neurogenic Orthostatic Hypotension: A Comparative Review. Cureus 2023; 15:e38907. [PMID: 37303338 PMCID: PMC10257554 DOI: 10.7759/cureus.38907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/11/2023] [Indexed: 06/13/2023] Open
Abstract
Neurogenic orthostatic hypotension (nOH) is a disabling problem of autonomic dysfunction in patients with Parkinson's disease, which is associated with poor quality of life and higher mortality rates. The purpose of this literature review was to explore and compare the efficacy and safety of droxidopa (an existing treatment) and ampreloxetine (a newer medication) in the treatment of nOH. We used a mixed-method literature review that addresses the epidemiology, pathophysiology, and pharmacological and non-pharmacological management of nOH in Parkinson's disease in a general way, with a more exploratory approach to droxidopa- and ampreloxetine-controlled trial studies. We included a total of 10 studies of randomized controlled trials with eight studies focused on droxidopa and two studies focused on ampreloxetine. These two drugs were analyzed and compared based on the collected individual study results. Treatment of nOH in Parkinson's disease patients with droxidopa or ampreloxetine showed clinically meaningful and statistically significant improvements relative to placebo on the components of the OHSA (Orthostatic Hypotension Symptom Assessment) composite score and OHDAS (Orthostatic Hypotension Daily Activity Scale composite scores) composite score. Droxidopa had an improved effect on daily activities, with an associated increase in standing systolic blood pressure (BP), but the long-term efficacy of droxidopa has not been documented. Standing systolic BP was maintained by ampreloxetine and worsened after the withdrawal phase. This highlights the importance of conducting further research which will help us to improve the therapeutic approach for patients with nOH and Parkinson's disease.
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Affiliation(s)
| | - Shruti Shah
- Internal Medicine, Byramjee Jeejeeboy (BJ) Medical College, Pune, IND
| | | | | | | | - Saumya Singh
- Internal Medicine, Gujarat Medical Education & Research Society (GMERS) Medical College and Hospital, Gujarat, IND
| | - Gaudy F Collado
- Internal Medicine, Fleet Medical Unit, Philippine Fleet, Philippine Navy, Cavite City, PHL
| | - Abhishek Goyal
- Internal Medicine, Kasturba Medical College, Manipal, Manipal, IND
| | - Imran Khawaja
- Internal Medicine, Ayub Medical Institute, Abbottabad, PAK
| | | | - Waleed Razzaq
- Internal Medicine, Services Hospital Lahore, Lahore, PAK
| | - Zain U Abdin
- Medicine, District Head Quarters Hospital, Faisalabad, PAK
| | - Ishita Gupta
- Medicine, Dr. Rajendra Prasad Government Medical College, Tanda, IND
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Fan HC, Chiang KL, Chang KH, Chen CM, Tsai JD. Epilepsy and Attention Deficit Hyperactivity Disorder: Connection, Chance, and Challenges. Int J Mol Sci 2023; 24:ijms24065270. [PMID: 36982345 PMCID: PMC10049646 DOI: 10.3390/ijms24065270] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 02/20/2023] [Accepted: 03/01/2023] [Indexed: 03/12/2023] Open
Abstract
Comorbidities are common in children with epilepsy, with nearly half of the patients having at least one comorbidity. Attention deficit hyperactivity disorder (ADHD) is a psychiatric disorder characterized by hyperactivity and inattentiveness level disproportional to the child’s developmental stage. The burden of ADHD in children with epilepsy is high and can adversely affect the patients’ clinical outcomes, psychosocial aspects, and quality of life. Several hypotheses were proposed to explain the high burden of ADHD in childhood epilepsy; the well-established bidirectional connection and shared genetic/non-genetic factors between epilepsy and comorbid ADHD largely rule out the possibility of a chance in this association. Stimulants are effective in children with comorbid ADHD, and the current body of evidence supports their safety within the approved dose. Nonetheless, safety data should be further studied in randomized, double-blinded, placebo-controlled trials. Comorbid ADHD is still under-recognized in clinical practice. Early identification and management of comorbid ADHD are crucial to optimize the prognosis and reduce the risk of adverse long-term neurodevelopmental outcomes. The identification of the shared genetic background of epilepsy and ADHD can open the gate for tailoring treatment options for these patients through precision medicine.
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Affiliation(s)
- Hueng-Chuen Fan
- Department of Pediatrics, Tungs’ Taichung Metroharbor Hospital, Wuchi, Taichung 435, Taiwan
- Department of Rehabilitation, Jen-Teh Junior College of Medicine, Nursing and Management, Miaoli 356, Taiwan
- Department of Life Sciences, Agricultural Biotechnology Center, National Chung Hsing University, Taichung 402, Taiwan
| | - Kuo-Liang Chiang
- Department of Pediatric Neurology, Kuang-Tien General Hospital, Taichung 433, Taiwan
- Department of Nutrition, Hungkuang University, Taichung 433, Taiwan
| | - Kuang-Hsi Chang
- Department of Medical Research, Tungs’ Taichung Metroharbor Hospital, Wuchi, Taichung 435, Taiwan
| | - Chuan-Mu Chen
- Department of Life Sciences, Agricultural Biotechnology Center, National Chung Hsing University, Taichung 402, Taiwan
- The iEGG and Animal Biotechnology Center, and Rong Hsing Research Center for Translational Medicine, National Chung Hsing University, Taichung 402, Taiwan
- Correspondence: (C.-M.C.); (J.-D.T.); Tel.: +886-4-22840319-701 (C.-M.C.); +886-4-24730022-21731 (J.-D.T.)
| | - Jeng-Dau Tsai
- School of Medicine, Chung Shan Medical University, Taichung 402, Taiwan
- Department of Pediatrics, Chung Shan Medical University Hospital, Taichung 402, Taiwan
- Correspondence: (C.-M.C.); (J.-D.T.); Tel.: +886-4-22840319-701 (C.-M.C.); +886-4-24730022-21731 (J.-D.T.)
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Bejjani A, Zhang Y, Behrens A, Murray B, Shah N. Droxidopa in the Management of Hepatorenal Syndrome. J Pharm Pract 2022:8971900221087974. [PMID: 35426352 DOI: 10.1177/08971900221087974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE Hepatorenal syndrome (HRS) is renal dysfunction associated with the hemodynamic consequences of advanced liver disease and cirrhosis. HRS is associated with a high mortality, and there remain high failure rates with first-line therapy aimed at improving perfusion. We report the use of droxidopa, an oral norepinephrine precursor, to aid in the management of HRS-AKI refractory to first-line therapy. SUMMARY A 51-year-old Caucasian male with alcohol-related cirrhosis presented with 1-week history of pre-syncope and falls. He was found to have acute kidney injury meeting diagnostic criteria of HRS based on absence of identifiable contributing factors. After no response to volume expansion, medical management was initiated with midodrine and octreotide and eventually escalated to norepinephrine intravenous infusion. The patient's renal function and urine output improved initially on norepinephrine, but worsened when attempting to wean to a suitable outpatient regimen, becoming dependent upon norepinephrine. On day 13 of hospitalization, droxidopa was initiated at a dose of 100 mg three times daily and titrated to a dose of 400 mg three times daily. Norepinephrine infusion was weaned and discontinued on day 16 of hospitalization. The patient remained hemodynamically stable and was able to be discharged on droxidopa 400 mg three times daily, midodrine 20 mg three times day, and octreotide 200 mcg three times daily. CONCLUSION Droxidopa, an oral norepinephrine precursor, presents a novel adjunctive agent for management of HRS refractory to first-line medical management.
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Affiliation(s)
- Andrea Bejjani
- Department of Pharmacy, 537791University of North Carolina Health, Chapel Hill, NC, USA
| | - Youqi Zhang
- Department of Pharmacy, 537791University of North Carolina Health, Chapel Hill, NC, USA
| | - Allison Behrens
- Department of Pharmacy, 537791University of North Carolina Health, Chapel Hill, NC, USA
| | - Brian Murray
- Department of Pharmacy, 537791University of North Carolina Health, Chapel Hill, NC, USA
| | - Neil Shah
- Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina, Chapel Hill, NC, USA
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Tanzer TD, Brouard T, Pra SD, Warren N, Barras M, Kisely S, Brooks E, Siskind D. Treatment strategies for clozapine-induced hypotension: a systematic review. Ther Adv Psychopharmacol 2022; 12:20451253221092931. [PMID: 35633931 PMCID: PMC9136453 DOI: 10.1177/20451253221092931] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 03/22/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Clozapine is the most effective medication for treatment-refractory schizophrenia but is associated with significant adverse drug effects, including hypotension and dizziness, which have a negative impact on quality of life and treatment compliance. Available evidence for the management of clozapine-induced hypotension is scant. OBJECTIVES Due to limited guidance on the safety and efficacy of pharmacological treatments for clozapine-induced hypotension, we set out to systematically review and assess the evidence for the management of clozapine-induced hypotension and provide guidance to clinicians, patients, and carers. DESIGN We undertook a systematic review of the safety and efficacy of interventions for clozapine-induced hypotension given the limited available evidence. DATA SOURCES AND METHODS PubMed, Embase, PsycINFO, CINAHL, and the Cochrane trial Registry were searched from inception to November 2021 for literature on the treatment strategies for clozapine-induced hypotension and dizziness using a PROSPERO pre-registered search strategy. For orthostatic hypotension, we developed a management framework to assist in the choice of intervention. RESULTS We identified nine case studies and four case series describing interventions in 15 patients. Hypotension interventions included temporary clozapine dose reduction, non-pharmacological treatments, and pharmacological treatments. Midodrine, fludrocortisone, moclobemide and Bovril® combination, and etilefrine were associated with improvement in symptoms or reduction in orthostatic hypotension. Angiotensin II, arginine vasopressin, and noradrenaline successfully restored and maintained mean arterial pressure in critical care situations. A paradoxical reaction of severe hypotension was reported with adrenaline use. CONCLUSION Orthostatic hypotension is a common side effect during clozapine titration. Following an assessment of the titration schedule, salt and fluid intake, and review of hypertensive and nonselective α1-adrenergic agents, first-line treatment should be a temporary reduction in clozapine dose or non-pharmacological interventions. If orthostatic hypotension persists, fludrocortisone should be trialled with monitoring of potassium levels and sodium and fluid intake. Midodrine may be considered second-line or where fludrocortisone is contraindicated or poorly tolerated. For patients on clozapine with hypotension in critical care settings, the use of adrenaline to maintain mean arterial pressure should be avoided. REGISTRATION PROSPERO (Registration No. CRD42020191530).
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Affiliation(s)
| | - Thomas Brouard
- Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Samuel Dal Pra
- Metro South Addiction and Mental Health Services, Brisbane, QLD, Australia
| | - Nicola Warren
- Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Michael Barras
- Department of Pharmacy, Princess Alexandra Hospital, Brisbane, QLD, Australia School of Pharmacy, The University of Queensland, Brisbane, QLD, Australia
| | - Steve Kisely
- Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Emily Brooks
- Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Dan Siskind
- Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
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Katsi V, Papakonstantinou I, Solomou E, Antonopoulos AS, Vlachopoulos C, Tsioufis K. Management of Hypertension and Blood Pressure Dysregulation in Patients with Parkinson's Disease-a Systematic Review. Curr Hypertens Rep 2021; 23:26. [PMID: 33961147 DOI: 10.1007/s11906-021-01146-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/16/2021] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW The aim of this review article was to summarize the cardiovascular and blood pressure profile regarding Parkinson disease patients and to provide an update on the recent advancements in the field of the diagnosis and management of blood pressure abnormalities in these patients. Our goal was to guide physicians to avoid pitfalls in current practice while treating patients with Parkinson disease and blood pressure abnormalities. For this purpose, we searched bibliographic databases (PubMed, Google Scholar) for all publications published on blood pressure effects in Parkinson disease until May 2020. Furthermore, we highlight some thoughts and potential perspectives for the next possible steps in the field. RECENT FINDINGS Blood pressure dysregulation in patients with Parkinson's disease has several implications in clinical practice and presents an ongoing concern. Compared with chronic essential hypertension, the syndrome of combined neurogenic orthostatic hypotension and supine hypertension in Parkinson's disease has received little attention. If left untreated, hypertension may lead to cardiovascular disease whereas hypotension may lead to fall-related complications, with tremendous impact on the quality of life of affected individuals. The effect of blood Epressure control and the risk of death from cardiovascular disease in Parkinson disease are largely unexplored. Blood pressure abnormalities in Parkinson disease present bidirectional relationship and the rationale for treating and controlling hypertension in persons with Parkinson disease and concurrent neurogenic orthostatic hypotension and/or supine hypertension is compelling. Further research is warranted in order to clarify the mechanisms, clinical implications, and potential reversibility of compromised cardiovascular function, in persons with Parkinson disease.
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Affiliation(s)
- Vasiliki Katsi
- Cardiology Department, Hippokration General Hospital, Athens, Greece. .,Internal Medicine, Evangelismos Hospital, Athens, Greece.
| | - Ilias Papakonstantinou
- Cardiology Department, Hippokration General Hospital, Athens, Greece.,Internal Medicine, Evangelismos Hospital, Athens, Greece
| | - Eirini Solomou
- Cardiology Department, Hippokration General Hospital, Athens, Greece.,Internal Medicine, Evangelismos Hospital, Athens, Greece
| | - Alexios S Antonopoulos
- Cardiology Department, Hippokration General Hospital, Athens, Greece.,Internal Medicine, Evangelismos Hospital, Athens, Greece
| | - Charalambos Vlachopoulos
- Cardiology Department, Hippokration General Hospital, Athens, Greece.,Internal Medicine, Evangelismos Hospital, Athens, Greece
| | - Konstantinos Tsioufis
- Cardiology Department, Hippokration General Hospital, Athens, Greece.,Internal Medicine, Evangelismos Hospital, Athens, Greece
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Brignole M, Rivasi G. New insights in diagnostics and therapies in syncope: a novel approach to non-cardiac syncope. Heart 2021; 107:864-873. [PMID: 33462120 DOI: 10.1136/heartjnl-2020-318261] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 12/29/2020] [Indexed: 12/27/2022] Open
Abstract
This article aims to give advice on how to identify and manage patients with syncope who are at risk of severe outcomes, that is, at risk of trauma, potentially life-threatening episodes or frequent recurrences reducing quality of life. The first step of syncope diagnostic assessment is to identify patients with cardiac syncope, and once established, these patients must receive the adequate mechanism-specific treatment. If cardiac syncope is unlikely, reflex (neurally mediated) syncope and orthostatic hypotension are the most frequent causes of transient loss of consciousness. For these presentations, efficacy of therapy is largely determined by the mechanism of syncope rather than its aetiology or clinical features. The identified mechanism of syncope should be carefully assessed and assigned either to hypotensive or bradycardic phenotype, which will determine the choice of therapy (counteracting hypotension or counteracting bradycardia). The results of recent trials indicate that 'mechanism-specific therapy' is highly effective in preventing recurrences. Established mechanism-specific treatment strategies include withdrawal of hypotensive drugs, applying fludrocortisone and midodrine for the hypotensive phenotype and cardiac pacing in the bradycardic phenotype.
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Affiliation(s)
- Michele Brignole
- Department of Cardiovascular, Neural and Metabolic Sciences, Faint & Fall Programme, IRCCS Istituto Auxologico Italiano, San Luca Hospital, Milan, Italy
| | - Giulia Rivasi
- Division of Geriatric and Intensive Care Medicine, University of Florence, Firenze, Italy
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11
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Rivasi G, Rafanelli M, Mossello E, Brignole M, Ungar A. Drug-Related Orthostatic Hypotension: Beyond Anti-Hypertensive Medications. Drugs Aging 2020; 37:725-738. [PMID: 32894454 PMCID: PMC7524811 DOI: 10.1007/s40266-020-00796-5] [Citation(s) in RCA: 60] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Orthostatic hypotension (OH) is an abnormal blood pressure response to standing, which is associated with an increased risk of adverse outcomes such as syncope, falls, cognitive impairment, and mortality. Medical therapy is one the most common causes of OH, since numerous cardiovascular and psychoactive medications may interfere with the blood pressure response to standing, leading to drug-related OH. Additionally, hypotensive medications frequently overlap with other OH risk factors (e.g., advanced age, neurogenic autonomic dysfunction, and comorbidities), thus increasing the risk of symptoms and complications. Consequently, a medication review is recommended as a first-line approach in the diagnostic and therapeutic work-up of OH, with a view to minimizing the risk of drug-related orthostatic blood pressure impairment. If symptoms persist after the review of hypotensive medications, despite adherence to non-pharmacological interventions, specific drug treatment for OH can be considered. In this narrative review we present an overview of drugs acting on the cardiovascular and central nervous system that may potentially impair the orthostatic blood pressure response and we provide practical suggestions that may be helpful to guide medical therapy optimization in patients with OH. In addition, we summarize the available strategies for drug treatment of OH in patients with persistent symptoms despite non-pharmacological interventions.
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Affiliation(s)
- Giulia Rivasi
- Syncope Unit and Referral Centre for Hypertension Management in Older Adults, Division of Geriatric and Intensive Care Medicine, Careggi Hospital and University of Florence and Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50139, Florence, Italy.
| | - Martina Rafanelli
- Syncope Unit and Referral Centre for Hypertension Management in Older Adults, Division of Geriatric and Intensive Care Medicine, Careggi Hospital and University of Florence and Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50139, Florence, Italy
| | - Enrico Mossello
- Syncope Unit and Referral Centre for Hypertension Management in Older Adults, Division of Geriatric and Intensive Care Medicine, Careggi Hospital and University of Florence and Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50139, Florence, Italy
| | - Michele Brignole
- IRCCS, Istituto Auxologico Italiano, Cardiology Unit and Department of Cardiovascular, Neural and Metabolic Sciences, S. Luca Hospital, Milan, Italy
| | - Andrea Ungar
- Syncope Unit and Referral Centre for Hypertension Management in Older Adults, Division of Geriatric and Intensive Care Medicine, Careggi Hospital and University of Florence and Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50139, Florence, Italy
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12
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Kalra DK, Raina A, Sohal S. Neurogenic Orthostatic Hypotension: State of the Art and Therapeutic Strategies. CLINICAL MEDICINE INSIGHTS-CARDIOLOGY 2020; 14:1179546820953415. [PMID: 32943966 PMCID: PMC7466888 DOI: 10.1177/1179546820953415] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 07/31/2020] [Indexed: 11/22/2022]
Abstract
Neurogenic orthostatic hypotension (nOH) is a subtype of orthostatic hypotension in which patients have impaired regulation of standing blood pressure due to autonomic dysfunction. Several primary and secondary causes of this disease exist. Patients may present with an array of symptoms making diagnosis difficult. This review article addresses the epidemiology, pathophysiology, causes, clinical features, and management of nOH. We highlight various pharmacological and non-pharmacological approaches to treatment, and review the recent guidelines and our approach to nOH.
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Affiliation(s)
- Dinesh K Kalra
- Division of Cardiology, Rush University Medical Center, Chicago, IL, USA
| | - Anvi Raina
- Department of Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Sumit Sohal
- Division of Internal Medicine, AMITA Health Saint Francis Hospital, Evanston, IL, USA
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Dimitriadis K, Tsioufis C, Tousoulis D. Management of the "notorious" refractory orthostatic hypotension: Let's think and further study droxidopa. J Clin Hypertens (Greenwich) 2019; 21:1315-1316. [PMID: 31368654 DOI: 10.1111/jch.13618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Kyriakos Dimitriadis
- First Cardiology Clinic, Hippokration Hospital, University of Athens, Athens, Greece
| | - Costas Tsioufis
- First Cardiology Clinic, Hippokration Hospital, University of Athens, Athens, Greece
| | - Dimitris Tousoulis
- First Cardiology Clinic, Hippokration Hospital, University of Athens, Athens, Greece
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Yadav R, Rukmani M, Pal P, Sathyaprabha T. Clinical management of neurogenic orthostatic hypotension. ANNALS OF MOVEMENT DISORDERS 2019. [DOI: 10.4103/aomd.aomd_24_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
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Aljohar A, Muayqil T, Aldeeri A, Jammah A, Hersi A, Alhabib K. Pure Autonomic Failure with Asymptomatic Hypertensive Urgency: A Case Report and Literature Review. Case Rep Neurol 2018; 10:357-362. [PMID: 30687067 PMCID: PMC6341310 DOI: 10.1159/000495605] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 11/19/2018] [Indexed: 11/19/2022] Open
Abstract
We report the case study of a 70-year-old gentleman who presented with isolated, slowly progressive dizziness after prolonged standing and was eventually diagnosed with pure autonomic failure. Initially, his symptoms improved with the use of midodrine and fludrocortisone, but gradually became refractory and disabling. Despite multiple therapeutic interventions, his symptoms persisted along with worsening supine hypertension. We discuss the challenges faced in the treatment of an uncommon condition and discuss the clinical utility of performing serial 24-h ambulatory monitoring to detect subclinical blood pressure fluctuations.
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Affiliation(s)
- Alwaleed Aljohar
- Department of Internal Medicine, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Taim Muayqil
- Division of Neurology, Department of Internal Medicine, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Abdulrahman Aldeeri
- Department of Internal Medicine, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Anwar Jammah
- Department of Internal Medicine, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Ahmad Hersi
- Department of Adult Cardiology, King Fahad Cardiac Center, King Saud University, Riyadh, Saudi Arabia
| | - Khalid Alhabib
- Department of Adult Cardiology, King Fahad Cardiac Center, King Saud University, Riyadh, Saudi Arabia
- *Prof. Khalid Alhabib, Department of Adult Cardiology, King Fahad Cardiac Center, King Saud University, PO Box 7805, Riyadh 11472 (Saudi Arabia), E-Mail
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Cheshire WP. Chemical pharmacotherapy for the treatment of orthostatic hypotension. Expert Opin Pharmacother 2018; 20:187-199. [DOI: 10.1080/14656566.2018.1543404] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Godbole GP, Aggarwal B. Review of management strategies for orthostatic hypotension in older people. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2018. [DOI: 10.1002/jppr.1484] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Gauri P. Godbole
- Gosford Hospital Pharmacy Department; Central Coast Local Health District; Gosford Australia
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Patrick K, Martin T. Effectiveness of droxidopa compared to midodrine in standing blood pressure and orthostatic tolerance in adults with neurogenic orthostatic hypotension: a systematic review protocol. ACTA ACUST UNITED AC 2017; 15:2287-2294. [PMID: 28902695 DOI: 10.11124/jbisrir-2016-003306] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
REVIEW QUESTION The question of this review is: what is the effectiveness of droxidopa compared to midodrine on standing blood pressure and orthostatic intolerance symptoms in adults with neurogenic orthostatic hypotension?
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Affiliation(s)
- Kelli Patrick
- 1School of Nursing, University of Mississippi Medical Center, Jackson, USA 2UMMC School of Nursing Evidence Based Practice and Research Team: a Joanna Briggs Institute Affiliated Group
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Zhou Y, Ke SJ, Qiu XP, Liu LB. Prevalence, risk factors, and prognosis of orthostatic hypotension in diabetic patients: A systematic review and meta-analysis. Medicine (Baltimore) 2017; 96:e8004. [PMID: 28885363 PMCID: PMC6392609 DOI: 10.1097/md.0000000000008004] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Orthostatic hypotension (OH) is a major clinical sign of cardiovascular autonomic dysfunction in diabetic patients. Our aim was to quantitatively evaluate the prevalence and risk factors of OH in patients with diabetes mellitus (DM) and assess its prognosis. METHODS A comprehensive search of the PubMed, Embase, China National Knowledge Infrastructure, VIP Chinese Journal, Wanfang, and SINOMED databases was conducted for related published work up to September 25, 2016, and manually searched eligible studies from the references in accordance with the inclusion criteria. RESULTS We included 21 studies in the analysis, with a total sample size of 13,772. The pooled prevalence of OH in DM was 24% (95% confidence interval [CI]: 19-28%). Potential risk factors, that is, glycosylated hemoglobin A (HbA1c) (odds ratio [OR], 1.13, 95% CI, 1.07-1.20), hypertension (OR, 1.02, 95% CI, 1.01-1.02), and diabetic nephropathy (OR, 2.37, 95% CI, 1.76-3.19), were significantly associated with OH in DM. In addition, the prognosis of OH in DM was associated with higher risk of total mortality and cardiovascular events. CONCLUSION The pooled prevalence of OH in DM appears high. HbA1c, hypertension, and diabetic nephropathy are risk factors for OH in DM. OH indicates poor prognosis in diabetic patients. Attention should be focused on diabetic patients with the stated risk factors to prevent OH.
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Abstract
OBJECTIVE To review the efficacy and safety of pharmacological and nonpharmacological strategies used to treat primary orthostatic hypotension (OH). DATA SOURCES A literature review using PubMed and MEDLINE databases searching hypotension, non-pharmacological therapy, midodrine, droxidopa, pyridostigmine, fludrocortisone, atomoxetine, pseudoephedrine, and octreotide was performed. STUDY SELECTION AND DATA EXTRACTION Randomized or observational studies, cohorts, case series, or case reports written in English between January 1970 and November 2016 that assessed primary OH treatment in adult patients were evaluated. DATA SYNTHESIS Based on the chosen criteria, it was found that OH patients make up approximately 15% of all syncope patients, predominantly as a result of cardiovascular or neurological insults, or offending medication. Nonpharmacological strategies are the primary treatment, such as discontinuing offending medications, switching medication administration to bedtime, avoiding large carbohydrate-rich meals, limiting alcohol, maintaining adequate hydration, adding salt to diet, and so on. If these fail, pharmacotherapy can help ameliorate symptoms, including midodrine, droxidopa, fludrocortisone, pyridostigmine, atomoxetine, sympathomimetic agents, and octreotide. CONCLUSIONS Midodrine and droxidopa possess the most evidence with respect to increasing blood pressure and alleviating symptoms. Pyridostigmine and fludrocortisone can be used in patients who fail to respond to these agents. Emerging evidence with low-dose atomoxetine is promising, especially in those with central autonomic failure, and may prove to be a viable alternative treatment option. Data surrounding other therapies such as sympathomimetic agents or octreotide are minimal. Medication management of primary OH should be guided by patient-specific factors, such as tolerability, adverse effects, and drug-drug and drug-disease interactions.
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Affiliation(s)
- Genevieve M Hale
- 1 Nova Southeastern University College of Pharmacy, Palm Beach Gardens, FL, USA
| | - Jose Valdes
- 1 Nova Southeastern University College of Pharmacy, Palm Beach Gardens, FL, USA
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Wang H, Yang G, Zhou J, Pei J, Zhang Q, Song X, Sun Z. Development and validation of a UPLC-MS/MS method for quantitation of droxidopa in human plasma: Application to a pharmacokinetic study. J Chromatogr B Analyt Technol Biomed Life Sci 2016; 1027:234-8. [PMID: 27311027 DOI: 10.1016/j.jchromb.2016.04.056] [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] [Received: 02/10/2016] [Revised: 04/19/2016] [Accepted: 04/28/2016] [Indexed: 10/21/2022]
Abstract
In this study, a simple and sensitive ultra performance liquid chromatography-tandem mass spectrometry (UPLC-MS/MS) method was developed and validated for quantitation of droxidopa in human plasma for the first time. A simple plasma protein precipitation method using methanol containing 3% formic acid was selected, and the separation was achieved by an Acquity UPLC™ BEH Amide column (2.1mm×50mm, 1.7μm) with a gradient elution using acetonitrile, ammonium formate buffer and formic acid as mobile phase. The detection of droxidopa and benserazide (internal standard, IS) was performed using positive-ion electrospray tandem mass spectrometry via multiple reaction monitoring (MRM). The precursor-to-product ion transitions m/z 214.2→m/z 152.0 for droxidopa, and m/z 258.1→m/z 139.1 for IS were used for quantification. A lower limit of quantification of 5.00ng/mL was achieved and the linear curve range was 5.00-4000ng/mL using a weighted (1/x(2)) linear regression model. Intra-assay and inter-assay precision was less than 10.2%, and the accuracy ranged from 0.1% to 2.1%. Stability, recovery and matrix effects were within the acceptance criteria recommended by the regulatory bioanalytical guidelines. The method was successfully applied to a pharmacokinetic study of droxidopa in healthy Chinese volunteers.
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Affiliation(s)
- Haidong Wang
- Department of Pharmacy, The First People's Hospital of Lianyungang, Jiangsu, Lianyungang 222002, PR China
| | - Guangsheng Yang
- Department of Pharmacy, The First People's Hospital of Lianyungang, Jiangsu, Lianyungang 222002, PR China
| | - Jinyu Zhou
- Department of Pharmacy, The First People's Hospital of Lianyungang, Jiangsu, Lianyungang 222002, PR China
| | - Jiang Pei
- Institute of Clinical Pharmacy, Jining First People's Hospital,Jining Medical University, Jining, 272000, PR China
| | - Qiangfeng Zhang
- Department of Pharmacy, The First People's Hospital of Lianyungang, Jiangsu, Lianyungang 222002, PR China
| | - Xingfa Song
- Department of Pharmacy, The First People's Hospital of Lianyungang, Jiangsu, Lianyungang 222002, PR China
| | - Zengxian Sun
- Department of Pharmacy, The First People's Hospital of Lianyungang, Jiangsu, Lianyungang 222002, PR China.
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Saladini F, Di Marco A, Palatini P. Autonomic Dysfunction: How to Identify and When to Treat? High Blood Press Cardiovasc Prev 2016; 23:237-43. [PMID: 27342243 DOI: 10.1007/s40292-016-0162-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Accepted: 06/06/2016] [Indexed: 11/29/2022] Open
Abstract
Cardiovascular autonomic dysfunction (AD) is a particular condition that can be detected by means of ambulatory blood pressure monitoring (ABPM). ABPM is helpful to identify some specific characteristics of haemodynamic AD, including non-dipping/reverse-dipping pattern, orthostatic and post-prandial hypotension and elevated blood pressure variability. These characteristics may be misdiagnosed with traditional, clinic blood pressure measurements. AD is relatively common in the real world. By analysing about 1000 recordings in a Cardiology unit, AD was found in 6.8 % of the exams. Several diseases may be the underlying causes of AD. In our sample half of the subjects were diabetic (54.4 %), 17.7 % were patients with alpha-synucleinopathy (Parkinson disease or multiple system atrophy), and 27.9 % had other underlying causes of AD including chronic kidney disease, α-lytic drug assumption and AD from unknown causes. According to the different aetiology, different clinical characteristics can be found, in particular in diabetics these peculiar aspects are less pronounced compared to the other subgroups. These characteristics have been found to be predictors of cardiovascular events, organ damage, and mortality. For these reasons, early identification of these behaviours is important, in order to better define patient's cardiovascular risk profile. As regard treatment of AD, several drugs have been tested, however none of this showed efficacy in all kinds of patients. Another open aspect is "safe" reference values for supine hypertension.
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Affiliation(s)
- Francesca Saladini
- Cardiology Unit, Town Hospital of Camposampiero, via Pietro Cosma 2, Camposampiero, Italy. .,Vascular Medicine, Department of Medicine, University of Padova, via Giustiniani, 2, 35128, Padua, Italy.
| | - Attilio Di Marco
- Cardiology Unit, Town Hospital of Camposampiero, via Pietro Cosma 2, Camposampiero, Italy
| | - Paolo Palatini
- Vascular Medicine, Department of Medicine, University of Padova, via Giustiniani, 2, 35128, Padua, Italy
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In Sinn D, Gibbons CH. Pathophysiology and Treatment of Orthostatic Hypotension in Parkinsonian Disorders. Curr Treat Options Neurol 2016; 18:28. [DOI: 10.1007/s11940-016-0410-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Feinstein DL, Kalinin S, Braun D. Causes, consequences, and cures for neuroinflammation mediated via the locus coeruleus: noradrenergic signaling system. J Neurochem 2016; 139 Suppl 2:154-178. [PMID: 26968403 DOI: 10.1111/jnc.13447] [Citation(s) in RCA: 116] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Revised: 11/23/2015] [Accepted: 11/24/2015] [Indexed: 12/31/2022]
Abstract
Aside from its roles in as a classical neurotransmitter involved in regulation of behavior, noradrenaline (NA) has other functions in the CNS. This includes restricting the development of neuroinflammatory activation, providing neurotrophic support to neurons, and providing neuroprotection against oxidative stress. In recent years, it has become evident that disruption of physiological NA levels or signaling is a contributing factor to a variety of neurological diseases and conditions including Alzheimer's disease (AD) and Multiple Sclerosis. The basis for dysregulation in these diseases is, in many cases, due to damage occurring to noradrenergic neurons present in the locus coeruleus (LC), the major source of NA in the CNS. LC damage is present in AD, multiple sclerosis, and a large number of other diseases and conditions. Studies using animal models have shown that experimentally induced lesion of LC neurons exacerbates neuropathology while treatments to compensate for NA depletion, or to reduce LC neuronal damage, provide benefit. In this review, we will summarize the anti-inflammatory and neuroprotective actions of NA, summarize examples of how LC damage worsens disease, and discuss several approaches taken to treat or prevent reductions in NA levels and LC neuronal damage. Further understanding of these events will be of value for the development of treatments for AD, multiple sclerosis, and other diseases and conditions having a neuroinflammatory component. The classical neurotransmitter noradrenaline (NA) has critical roles in modulating behaviors including those involved in sleep, anxiety, and depression. However, NA can also elicit anti-inflammatory responses in glial cells, can increase neuronal viability by inducing neurotrophic factor expression, and can reduce neuronal damage due to oxidative stress by scavenging free radicals. NA is primarily produced by tyrosine hydroxylase (TH) expressing neurons in the locus coeruleus (LC), a relatively small brainstem nucleus near the IVth ventricle which sends projections throughout the brain and spinal cord. It has been known for close to 50 years that LC neurons are lost during normal aging, and that loss is exacerbated in neurological diseases including Parkinson's disease and Alzheimer's disease. LC neuronal damage and glial activation has now been documented in a variety of other neurological conditions and diseases, however, the causes of LC damage and cell loss remain largely unknown. A number of approaches have been developed to address the loss of NA and increased inflammation associated with LC damage, and several methods are being explored to directly minimize the extent of LC neuronal cell loss or function. In this review, we will summarize some of the consequences of LC loss, consider several factors that likely contribute to that loss, and discuss various ways that have been used to increase NA or to reduce LC damage. This article is part of the 60th Anniversary special issue.
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Affiliation(s)
- Douglas L Feinstein
- Department of Anesthesiology, University of Illinois, Chicago, IL, USA. .,Jesse Brown VA Medical Center, Chicago, IL, USA.
| | - Sergey Kalinin
- Department of Anesthesiology, University of Illinois, Chicago, IL, USA.,Jesse Brown VA Medical Center, Chicago, IL, USA
| | - David Braun
- Department of Anesthesiology, University of Illinois, Chicago, IL, USA.,Jesse Brown VA Medical Center, Chicago, IL, USA
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Ricci F, De Caterina R, Fedorowski A. Orthostatic Hypotension. J Am Coll Cardiol 2015; 66:848-860. [DOI: 10.1016/j.jacc.2015.06.1084] [Citation(s) in RCA: 254] [Impact Index Per Article: 28.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Revised: 06/12/2015] [Accepted: 06/15/2015] [Indexed: 01/07/2023]
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