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Skylynn T, Abel T, Christopher L, Suliman G, Dominic R, Joel V, Yu Z, Pemminati S. Benefits and Risks of Medications Used in the Management of Hypotension: A Review. Cureus 2024; 16:e51608. [PMID: 38313995 PMCID: PMC10837047 DOI: 10.7759/cureus.51608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/02/2024] [Indexed: 02/06/2024] Open
Abstract
This comprehensive literature review addresses the scarcity and limited study of hypotension treatments compared to abundant antihypertensive drugs. Hypotension, categorized as absolute, relative, or orthostatic, has diverse causes. This review explores various treatments, including drugs affecting the sympathetic nervous system, such as midodrine, dihydroergotamine, and ergotamine, which have shown efficacy in managing hypotension. Dopamine agonists/antagonists and other drugs such as ephedrine, norepinephrine, and fludrocortisone are also discussed, each with distinct mechanisms and applications. Additionally, adjunctive agents such as non-steroidal anti-inflammatory agents, caffeine, and monoamine oxidase inhibitors are reviewed for their effects on blood pressure. This review underscores the importance of understanding the efficacy and safety profiles of hypotension treatments to guide healthcare professionals in optimal drug selection and management, emphasizing the need for further research and comparative studies for evidence-based guidelines.
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Affiliation(s)
- Thangwaritorn Skylynn
- Department of Biomedical Education, California Health Sciences University College of Osteopathic Medicine, Clovis, USA
| | - Thomas Abel
- Department of Biomedical Education, California Health Sciences University College of Osteopathic Medicine, Clovis, USA
| | - Lee Christopher
- Department of Biomedical Education, California Health Sciences University College of Osteopathic Medicine, Clovis, USA
| | - Ghafary Suliman
- Department of Biomedical Education, California Health Sciences University College of Osteopathic Medicine, Clovis, USA
| | - Rivera Dominic
- Department of Biomedical Education, California Health Sciences University College of Osteopathic Medicine, Clovis, USA
| | - Varughese Joel
- Department of Biomedical Education, California Health Sciences University College of Osteopathic Medicine, Clovis, USA
| | - Zeyu Yu
- Department of Biomedical Education, California Health Sciences University College of Osteopathic Medicine, Clovis, USA
| | - Sudhakar Pemminati
- Department of Pharmacology, California Health Sciences University College of Osteopathic Medicine, Clovis, USA
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Eschlböck S, Wenning G, Fanciulli A. Evidence-based treatment of neurogenic orthostatic hypotension and related symptoms. J Neural Transm (Vienna) 2017; 124:1567-1605. [PMID: 29058089 PMCID: PMC5686257 DOI: 10.1007/s00702-017-1791-y] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Accepted: 09/18/2017] [Indexed: 02/06/2023]
Abstract
Neurogenic orthostatic hypotension, postprandial hypotension and exercise-induced hypotension are common features of cardiovascular autonomic failure. Despite the serious impact on patient’s quality of life, evidence-based guidelines for non-pharmacological and pharmacological management are lacking at present. Here, we provide a systematic review of the literature on therapeutic options for neurogenic orthostatic hypotension and related symptoms with evidence-based recommendations according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE). Patient’s education and non-pharmacological measures remain essential, with strong recommendation for use of abdominal binders. Based on quality of evidence and safety issues, midodrine and droxidopa reach a strong recommendation level for pharmacological treatment of neurogenic orthostatic hypotension. In selected cases, a range of alternative agents can be considered (fludrocortisone, pyridostigmine, yohimbine, atomoxetine, fluoxetine, ergot alkaloids, ephedrine, phenylpropanolamine, octreotide, indomethacin, ibuprofen, caffeine, methylphenidate and desmopressin), though recommendation strength is weak and quality of evidence is low (atomoxetine, octreotide) or very low (fludrocortisone, pyridostigmine, yohimbine, fluoxetine, ergot alkaloids, ephedrine, phenylpropanolamine, indomethacin, ibuprofen, caffeine, methylphenidate and desmopressin). In case of severe postprandial hypotension, acarbose and octreotide are recommended (strong recommendation, moderate level of evidence). Alternatively, voglibose or caffeine, for which a weak recommendation is available, may be useful.
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Affiliation(s)
- Sabine Eschlböck
- Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Gregor Wenning
- Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Alessandra Fanciulli
- Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.
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Celedonio JE, Arnold AC, Dupont WD, Ramirez CE, Diedrich A, Okamoto LE, Raj SR, Robertson D, Peltier AC, Biaggioni I, Shibao CA. Residual sympathetic tone is associated with reduced insulin sensitivity in patients with autonomic failure. Clin Auton Res 2015; 25:309-15. [PMID: 26359268 DOI: 10.1007/s10286-015-0307-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Accepted: 06/18/2015] [Indexed: 11/28/2022]
Abstract
PURPOSE Parkinson disease, an α-synucleinopathy, is associated with reduced insulin sensitivity, impaired glucose tolerance, and diabetes mellitus. Importantly, these metabolic alterations have been shown to contribute to disease progression. The purpose of this study was to determine if reduced insulin sensitivity is also present in other α-synucleinopathies associated with autonomic failure. METHODS We studied 19 patients with multiple system atrophy and 26 patients with pure autonomic failure. For comparison, we studied 8 healthy controls matched for body mass index. Insulin sensitivity and beta cell function were calculated using fasting glucose and insulin levels according to the homeostatic model assessment 2. A multiple linear regression model was performed to determine factors that predict insulin sensitivity in autonomic failure. RESULTS There was a significant difference in insulin sensitivity among groups (P = 0.048). This difference was due to lower insulin sensitivity in multiple system atrophy patients: 64% [interquartile range (IQR), 43 to 117] compared to healthy controls 139% (IQR, 83 to 212), P = 0.032. The main factor that contributed to the reduced insulin sensitivity was the presence of supine hypertension and residual sympathetic tone. CONCLUSIONS Multiple system atrophy patients have reduced insulin sensitivity that is associated with residual sympathetic activation and supine hypertension. These patients may therefore be at high risk for development of impaired glucose tolerance and diabetes mellitus.
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Affiliation(s)
- Jorge E Celedonio
- Division of Clinical Pharmacology, Department of Medicine, The Autonomic Dysfunction Center, Vanderbilt University School of Medicine, 562 Preston Research Building, Nashville, TN, 37232, USA
| | - Amy C Arnold
- Division of Clinical Pharmacology, Department of Medicine, The Autonomic Dysfunction Center, Vanderbilt University School of Medicine, 562 Preston Research Building, Nashville, TN, 37232, USA
| | - William D Dupont
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, USA
| | - Claudia E Ramirez
- Division of Clinical Pharmacology, Department of Medicine, The Autonomic Dysfunction Center, Vanderbilt University School of Medicine, 562 Preston Research Building, Nashville, TN, 37232, USA
| | - André Diedrich
- Division of Clinical Pharmacology, Department of Medicine, The Autonomic Dysfunction Center, Vanderbilt University School of Medicine, 562 Preston Research Building, Nashville, TN, 37232, USA
| | - Luis E Okamoto
- Division of Clinical Pharmacology, Department of Medicine, The Autonomic Dysfunction Center, Vanderbilt University School of Medicine, 562 Preston Research Building, Nashville, TN, 37232, USA
| | - Satish R Raj
- Division of Clinical Pharmacology, Department of Medicine, The Autonomic Dysfunction Center, Vanderbilt University School of Medicine, 562 Preston Research Building, Nashville, TN, 37232, USA
| | - David Robertson
- Division of Clinical Pharmacology, Department of Medicine, The Autonomic Dysfunction Center, Vanderbilt University School of Medicine, 562 Preston Research Building, Nashville, TN, 37232, USA
| | - Amanda C Peltier
- Department of Neurology, The Autonomic Dysfunction Center, Vanderbilt University School of Medicine, Nashville, USA
| | - Italo Biaggioni
- Division of Clinical Pharmacology, Department of Medicine, The Autonomic Dysfunction Center, Vanderbilt University School of Medicine, 562 Preston Research Building, Nashville, TN, 37232, USA
| | - Cyndya A Shibao
- Division of Clinical Pharmacology, Department of Medicine, The Autonomic Dysfunction Center, Vanderbilt University School of Medicine, 562 Preston Research Building, Nashville, TN, 37232, USA.
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Schroeder C, Jordan J, Kaufmann H. Management of neurogenic orthostatic hypotension in patients with autonomic failure. Drugs 2014; 73:1267-79. [PMID: 23857549 DOI: 10.1007/s40265-013-0097-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The maintenance of blood pressure in the upright position requires intact autonomic cardiovascular reflexes. Diseases that affect the sympathetic innervation of the cardiovascular system result in a sustained fall in blood pressure upon standing (i.e., neurogenic orthostatic hypotension) that can impair the blood supply to the brain and other organs and cause considerable morbidity and mortality. Here we review treatment options for neurogenic orthostatic hypotension and include an algorithm for its management that emphasizes the importance of non-pharmacologic measures and provides guidance on pharmacologic treatment options.
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Affiliation(s)
- Christoph Schroeder
- Institute of Clinical Pharmacology, OE 5350, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625, Germany.
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Low DA, da Nóbrega AC, Mathias CJ. Exercise-induced hypotension in autonomic disorders. Auton Neurosci 2012; 171:66-78. [DOI: 10.1016/j.autneu.2012.07.008] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2012] [Revised: 07/25/2012] [Accepted: 07/26/2012] [Indexed: 11/30/2022]
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Mathias CJ, Kimber JR. Postural hypotension: causes, clinical features, investigation, and management. Annu Rev Med 1999; 50:317-36. [PMID: 10073281 DOI: 10.1146/annurev.med.50.1.317] [Citation(s) in RCA: 64] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Postural hypotension may result from various neurogenic and non-neurogenic causes. It may be a key feature of certain disorders, such as the primary chronic autonomic failure syndromes; it can complicate a variety of diseases, such as diabetes mellitus; and its prevalence increases with advancing age. When symptomatic, it may result in loss of consciousness and thus cause injury. Postural hypotension can be suspected from the patient's history and is readily documented in the clinic by measuring lying and standing blood pressure. The diagnosis ideally should be confirmed in the laboratory with additional tests to determine the cause and evaluate the functional deficit, so as to aid treatment. Treatment of the causative disorder is often curative when there are non-neurogenic causes. A combination of nonpharmacological and pharmacological measures is needed in the management of neurogenic postural hypotension.
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Affiliation(s)
- C J Mathias
- Neurovascular Medicine Unit, Imperial College School of Medicine at St Mary's, London, United Kingdom.
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Plaschke M, Trenkwalder P, Dahlheim H, Lechner C, Trenkwalder C. Twenty-four-hour blood pressure profile and blood pressure responses to head-up tilt tests in Parkinson's disease and multiple system atrophy. J Hypertens 1998; 16:1433-41. [PMID: 9814613 DOI: 10.1097/00004872-199816100-00006] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To investigate the 24 h blood pressure profile in patients with Parkinson's disease with intact autonomic function or with autonomic failure and patients with multiple system atrophy (MSA), and to assess whether these patients exhibit posture-related variations in blood pressure. PATIENTS AND METHODS We studied 24 patients with Parkinson's disease (11 with autonomic failure) and 13 patients with MSA (all with autonomic failure). Autonomic failure was determined by autonomic tests. An oscillometric recorder was used for ambulatory blood pressure monitoring. Tilt-table tests were performed with a head-up tilt position of 60 degrees. RESULTS An alteration in the normal 24 h blood pressure profile was observed in 82% of Parkinson's disease patients with autonomic failure and in 85% of those with multiple system atrophy, but not in the patients with intact autonomic function. Head-up tilt tests revealed a significantly higher supine blood pressure in Parkinson's disease patients with autonomic failure and in those with MSA than in Parkinson's disease patients with intact autonomic function. Tilting resulted in a marked fall in blood pressure in patients with MSA; in Parkinson's disease patients with autonomic failure, the fall was comparatively slighter. CONCLUSIONS We conclude that autonomic failure contributes to the alterations in the day-night blood pressure profile that may possibly be ascribed to postural dysregulation of blood pressure. We hypothesize that nocturnal hypertension is a risk factor in the development of additional cerebrovascular disease in patients with Parkinson's disease or MSA who are affected by autonomic failure.
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Affiliation(s)
- M Plaschke
- Max Planck Institute of Psychiatry, Department of Neurology and Clinical Neurophysiology, Munich, Germany
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Abstract
The splanchnic circulation is one of the largest vascular regions in man. In the past, this has been difficult to study because of methodological problems. The adapting of noninvasive Doppler techniques has made it possible to develop reproducible measurements of coeliac and superior mesenteric artery blood flow, which are the main contributors to the gastrointestinal vasculature. This has resulted in the further understanding of neurogenic and humoral control of this region in a number of physiological and pathophysiological states, and has contributed towards the knowledge of its pharmacological control. These studies are of relevance to cardiovascular homeostasis and, in particular, systemic blood pressure control which depends upon various factors including responses in different vascular regions. In this review the key physiological factors which influence pharmacological studies on this circulation will be discussed. Examples will be provided, in subjects with cardiovascular and neurological disorders, of how administration of endogenous and exogenous substances, including drugs with specific pharmacological effects, alter human gastrointestinal blood flow. These will include insulin, alcohol, the somatostatin analogue octreotide, the central acting sympatholytic clonidine and the angiotensin II-converting inhibitor captopril. The relevance of these studies to subjects with postural hypotension due to sympathetic denervation and to primary hypertension, in particular, will be discussed.
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Affiliation(s)
- C J Mathias
- Department of Medicine, St Mary's Hospital/Imperial College School of Medicine, London, UK
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