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Ahmadi H, Herat N, Alizadeh S, Button DC, Granacher U, Behm DG. Effect of an inverted seated position with upper arm blood flow restriction on measures of elbow flexors neuromuscular performance. PLoS One 2021; 16:e0245311. [PMID: 34010275 PMCID: PMC8133415 DOI: 10.1371/journal.pone.0245311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 04/28/2021] [Indexed: 11/20/2022] Open
Abstract
Purpose The objective of the investigation was to determine the concomitant effects of upper arm blood flow restriction (BFR) and inversion on elbow flexors neuromuscular responses. Methods Randomly allocated, 13 volunteers performed four conditions in a within-subject design: rest (control, 1-min upright position without BFR), control (1-min upright with BFR), 1-min inverted (without BFR), and 1-min inverted with BFR. Evoked and voluntary contractile properties, before, during and after a 30-s maximum voluntary contraction (MVC) exercise intervention were examined as well as pain scale. Results Inversion induced significant pre-exercise intervention decreases in elbow flexors MVC (21.1%, ηp2 = 0.48, p = 0.02) and resting evoked twitch forces (29.4%, ηp2 = 0.34, p = 0.03). The 30-s MVC induced significantly greater pre- to post-test decreases in potentiated twitch force ( ηp2 = 0.61, p = 0.0009) during inversion (↓75%) than upright (↓65.3%) conditions. Overall, BFR decreased MVC force 4.8% ( ηp2 = 0.37, p = 0.05). For upright position, BFR induced 21.0% reductions in M-wave amplitude ( ηp2 = 0.44, p = 0.04). There were no significant differences for electromyographic activity or voluntary activation as measured with the interpolated twitch technique. For all conditions, there was a significant increase in pain scale between the 40–60 s intervals and post-30-s MVC (upright<inversion, and without BFR<BFR). Conclusion The concomitant application of inversion with elbow flexors BFR only amplified neuromuscular performance impairments to a small degree. Individuals who execute forceful contractions when inverted or with BFR should be cognizant that force output may be impaired.
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Affiliation(s)
- Hamid Ahmadi
- School of Human Kinetics and Recreation, Memorial University of Newfoundland, St. John’s, Newfoundland and Labrador, Canada
| | - Nehara Herat
- School of Human Kinetics and Recreation, Memorial University of Newfoundland, St. John’s, Newfoundland and Labrador, Canada
| | - Shahab Alizadeh
- School of Human Kinetics and Recreation, Memorial University of Newfoundland, St. John’s, Newfoundland and Labrador, Canada
| | - Duane C. Button
- School of Human Kinetics and Recreation, Memorial University of Newfoundland, St. John’s, Newfoundland and Labrador, Canada
| | - Urs Granacher
- Division of Training and Movement Science, University of Potsdam, Potsdam, Germany
| | - David G. Behm
- School of Human Kinetics and Recreation, Memorial University of Newfoundland, St. John’s, Newfoundland and Labrador, Canada
- * E-mail:
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Veazie S, Peterson K, Ansari Y, Chung KA, Gibbons CH, Raj SR, Helfand M. Fludrocortisone for orthostatic hypotension. Cochrane Database Syst Rev 2021; 5:CD012868. [PMID: 34000076 PMCID: PMC8128337 DOI: 10.1002/14651858.cd012868.pub2] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Orthostatic hypotension is an excessive fall in blood pressure (BP) while standing and is the result of a decrease in cardiac output or defective or inadequate vasoconstrictor mechanisms. Fludrocortisone is a mineralocorticoid that increases blood volume and blood pressure. Fludrocortisone is considered the first- or second-line pharmacological therapy for orthostatic hypotension alongside mechanical and positional measures such as increasing fluid and salt intake and venous compression methods. However, there has been no Cochrane Review of the benefits and harms of this drug for this condition. OBJECTIVES To identify and evaluate the benefits and harms of fludrocortisone for orthostatic hypotension. SEARCH METHODS We searched the following databases on 11 November 2019: Cochrane Neuromuscular Specialised Register, CENTRAL, MEDLINE, Embase and CINAHL. We also searched trials registries. SELECTION CRITERIA We included all studies evaluating the benefits and harms of fludrocortisone compared to placebo, another drug for orthostatic hypotension, or studies without comparators, including randomized controlled trials (RCTs), quasi-RCTs and observational studies. We included studies in people with orthostatic hypotension due to a chronic peripheral neuropathy, a central autonomic neuropathy, or autonomic failure from other causes, but not medication-induced orthostatic hypotension or orthostatic hypotension from acute volume depletion or blood loss. DATA COLLECTION AND ANALYSIS We used Cochrane methodological procedures for most of the review. We developed and used a tool to prioritize observational studies that offered the best available evidence where there are gaps in the evidence from RCTs. We assessed the certainty of evidence for fludrocortisone versus placebo using GRADE. MAIN RESULTS We included 13 studies of 513 participants, including three cross-over RCTs and 10 observational studies (three cohort studies, six case series and one case-control study). The included RCTs were small (total of 28 participants in RCTs), short term (two to three weeks), only examined fludrocortisone for orthostatic hypotension in people with two conditions (diabetes and Parkinson disease), and had variable risk of bias (two had unclear risk of bias and one had low risk of bias). Heterogeneity in participant populations, comparators and outcome assessment methods prevented meta-analyses of the RCTs. We found very low-certainty evidence about the effects of fludrocortisone versus placebo on drop in BP in people with diabetes (-26 mmHg versus -39 mmHg systolic; -7 mmHg versus -11 mmHg diastolic; 1 cross-over study, 6 participants). For people with Parkinson disease, we found very-low certainty evidence about the effects of fludrocortisone on drop in BP compared to pyridostigmine (-14 mmHg versus -22.1 mmHg diastolic; P = 0.036; 1 cross-over study, 9 participants) and domperidone (no change after treatment in either group; 1 cross-over study, 13 participants). For orthostatic symptoms, we found very low-certainty evidence for fludrocortisone versus placebo in people with diabetes (4 out of 5 analyzed participants had improvements in orthostatic symptoms, 1 cross-over study, 6 participants), for fludrocortisone versus pyridostigmine in people with Parkinson disease (orthostatic symptoms unchanged; 1 cross-over study, 9 participants) or fludrocortisone versus domperidone (improvement to 6 for both interventions on the Composite Autonomic Symptom Scale-Orthostatic Domain (COMPASS-OD); 1 cross-over study, 13 participants). Evidence on adverse events was also very low-certainty in both populations, but indicated side effects were minimal. Observational studies filled some gaps in evidence by examining the effects in larger groups of participants, with more diverse conditions, over longer periods of time. One cohort study (341 people studied retrospectively) found fludrocortisone may not be harmful in the long term for familial dysautonomia. However, it is unclear if this translates to long-term improvements in BP drop or a meaningful improvement in orthostatic symptoms. AUTHORS' CONCLUSIONS The evidence is very uncertain about the effects of fludrocortisone on blood pressure, orthostatic symptoms or adverse events in people with orthostatic hypotension and diabetes or Parkinson disease. There is a lack of information on long-term treatment and treatment of orthostatic hypotension in other disease states. There is a need for standardized reporting of outcomes and for standardization of measurements of blood pressure in orthostatic hypotension.
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Affiliation(s)
- Stephanie Veazie
- Scientific Resource Center, VA Portland Health Care System, Portland, Oregon, USA
| | - Kim Peterson
- Evidence-based Synthesis Program Coordinating Center, VA Portland Health Care System, Portland, Oregon, USA
| | - Yasmin Ansari
- Internal Medicine and Geriatrics, Oregon Health & Science University, Portland, Oregon, USA
| | - Kathryn A Chung
- Neurology, Oregon Health & Science University, Portland, Oregon, USA
| | | | - Satish R Raj
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, Calgary, Canada
| | - Mark Helfand
- Medicine, Medical Informatics & Clinical Epidemiology, Oregon Health Sciences University, Portland, Oregon, USA
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Biswas D, Karabin B, Turner D. Role of nurses and nurse practitioners in the recognition, diagnosis, and management of neurogenic orthostatic hypotension: a narrative review. Int J Gen Med 2019; 12:173-184. [PMID: 31118743 PMCID: PMC6501706 DOI: 10.2147/ijgm.s170655] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Neurogenic orthostatic hypotension (nOH) is a sustained reduction in blood pressure (BP) upon standing that is caused by autonomic dysfunction and is common among patients with a variety of neurodegenerative disorders (eg, Parkinson's disease, multiple system atrophy, pure autonomic failure). A systolic BP drop of ≥20 mmHg (or ≥10 mmHg diastolic) upon standing with little or no compensatory increase in heart rate is consistent with nOH. Symptoms of nOH include light-headedness, dizziness, presyncope, and syncope; these symptoms can severely impact patients' activities of daily living and increase the likelihood of potentially dangerous falls. Because of their patient contact, nurses and nurse practitioners can play a key role in identifying and evaluating patients at risk for nOH. It is advisable to screen for nOH in patients presenting with one or more of the following characteristics: those who have disorders associated with autonomic failure, those with episodes of falls or syncope, those with symptoms upon standing, those who are elderly or frail, or those taking multiple medications. Initial evaluations should include questions about postural symptoms and measurement of orthostatic BP and heart rate. A review of medications for potential agents that can have hypotensive effects should be performed before initiating treatment. Treatment for nOH may include non-pharmacologic measures and pharmacologic therapy. Droxidopa and midodrine are approved by the US Food and Drug Administration for the treatment of symptomatic nOH and symptomatic OH, respectively. nOH is associated with the coexistence of supine hypertension, and the two disorders must be carefully managed. In conclusion, timely screening and diagnosis of patients with nOH can streamline the path to disease management and treatment, potentially improving patient outcomes.
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Affiliation(s)
- Debashis Biswas
- Neurology, Baptist Memorial Hospital-Memphis, Memphis, TN, USA,
| | - Beverly Karabin
- Cardiovascular Medicine, University of Toledo, Toledo, OH, USA
| | - Debra Turner
- Autonomic Services, Semmes Murphey Clinic, Memphis, TN, 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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Castro Caldas A, Levin J, Djaldetti R, Rascol O, Wenning G, Ferreira JJ. Critical appraisal of clinical trials in multiple system atrophy: Toward better quality. Mov Disord 2017; 32:1356-1364. [PMID: 28782838 DOI: 10.1002/mds.27080] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Revised: 05/02/2017] [Accepted: 05/19/2017] [Indexed: 01/20/2023] Open
Abstract
Multiple system atrophy (MSA) is a rare neurodegenerative disease of undetermined cause. Although many clinical trials have been conducted, there is still no treatment that cures the disease or slows its progression. We sought to assess the clinical trials, methodology, and quality of reporting of clinical trails conducted in MSA patients. We conducted a systematic review of all trials with at least 1 MSA patient subject to any pharmacological/nonpharmacological interventions. Two independent reviewers evaluated the methodological characteristics and quality of reporting of trials. A total of 60 clinical trials were identified, including 1375 MSA patients. Of the trials, 51% (n = 31) were single-arm studies. A total of 28% (n = 17) had a parallel design, half of which (n = 13) were placebo controlled. Of the studies, 8 (13.3%) were conducted in a multicenter setting, 3 of which were responsible for 49.3% (n = 678) of the total included MSA patients. The description of primary outcomes was unclear in 60% (n = 40) of trials. Only 10 (16.7%) clinical trials clearly described the randomization process. Blinding of the participants, personnel, and outcome assessments were at high risk of bias in the majority of studies. The number of dropouts/withdrawals was high (n = 326, 23.4% among the included patients). Overall, the design and quality of reporting of the reviewed studies is unsatisfactory. The most frequent clinical trials were small and single centered. Inadequate reporting was related to the information on the randomization process, sequence generation, allocation concealment, blinding of participants, and sample size calculations. Although improved during the recent years, methodological quality and trial design need to be optimized to generate more informative results. © 2017 International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Ana Castro Caldas
- Neurology Service, Department of Neurosciences, Hospital de Santa Maria, Lisbon, Portugal.,Clinical Pharmacology Unit, Instituto de Medicina Molecular, Lisbon, Portugal.,Campus Neurológico Sénior, Torres Vedras, Portugal
| | - Johannes Levin
- Department of Neurology, Ludwig-Maximilians-Universität München, Munich, Germany.,German Center for Neurodegenerative Diseases, Munich, Germany
| | - Ruth Djaldetti
- Department of Neurology, Rabin Medical Center, Beilinson Campus, Petach Tikva, Israel
| | - Olivier Rascol
- Department of Neurosciences and Clinical Pharmacology, Reference Center for MSA, Clinical Investigation Center (CIC) 1436, and NeuroToul Center of Excellence in Neurodegeneration (COEN) Center, University of Toulouse, Institut national de la santé et de la recherche médicale (INSERM), University Hospital of Toulouse, Toulouse, France
| | - Gregor Wenning
- Department of Neurology, University Hospital, Innsbruck, Austria
| | - Joaquim J Ferreira
- Clinical Pharmacology Unit, Instituto de Medicina Molecular, Lisbon, Portugal.,Laboratory of Clinical Pharmacology and Therapeutics, Faculty of Medicine, University of Lisbon, Lisbon, Portugal
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Serrador JM, Freeman R. Enhanced Cholinergic Activity Improves Cerebral Blood Flow during Orthostatic Stress. Front Neurol 2017; 8:103. [PMID: 28373858 PMCID: PMC5357636 DOI: 10.3389/fneur.2017.00103] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Accepted: 03/02/2017] [Indexed: 02/05/2023] Open
Abstract
Cerebral blood flow (CBF) and consequently orthostatic tolerance when upright depends on dilation of the cerebral vasculature in the face of reduced perfusion pressure associated with the hydrostatic gradient. However, it is still unclear if cholinergic activation plays a role in this dilation. To determine if enhancing central cholinergic activity with the centrally acting acetylcholinesterase inhibitor, physostigmine would increase CBF when upright compared to the peripherally acting acetylcholinesterase inhibitor, neostigmine, or saline. We performed a randomized double-blind dose-ranging study that took place over 3 days in a hospital-based research lab. Eight healthy controls (six women and two men, mean age, 26 years; range 21–33) were given infusions of physostigmine, neostigmine, or saline on three different days. Five-minute tilts were repeated at baseline (no infusion), Dose 1 (0.2 μg/kg/min physostigmine; 0.1 μg/kg/min neostigmine) and Dose 2 (0.6 μg/kg/min physostigmine or 0.3 μg/kg/min neostigmine), and placebo (0.9% NaCl). Cerebral blood velocity, beat-to-beat blood pressure, and end-tidal CO2 were continuously measured during tilts. Physostigmine (0.6 μg/kg/min) resulted in higher cerebral blood velocity during tilt (90.5 ± 1.5%) than the equivalent neostigmine (85.5 ± 2.6%) or saline (84.8 ± 1.7%) trials (P < 0.05). This increase occurred despite a greater postural hypocapnia, suggesting physostigmine had a direct vasodilatory effect on the cerebral vasculature. Cerebral hypoperfusion induced by repeated tilts was eliminated by infusion of physostigmine not neostigmine. In conclusion, this study provides the first evidence that enhancement of central, not peripheral, cholinergic activity attenuates the physiological decrease in CBF seen during upright tilt. These data support the need for further research to determine if enhancing central cholinergic activity may improve symptoms in patients with symptomatic orthostatic intolerance.
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Affiliation(s)
- Jorge M Serrador
- Department of Pharmacology, Physiology and Neuroscience, Rutgers Biomedical Health Sciences, Newark, NJ, USA; Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Cardiovascular Electronics, National University of Ireland Galway, Galway, Ireland
| | - Roy Freeman
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School , Boston, MA , USA
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Schreglmann SR, Büchele F, Sommerauer M, Epprecht L, Kägi G, Hägele-Link S, Götze O, Zimmerli L, Waldvogel D, Baumann CR. Pyridostigmine bromide versus fludrocortisone in the treatment of orthostatic hypotension in Parkinson's disease - a randomized controlled trial. Eur J Neurol 2017; 24:545-551. [PMID: 28224720 DOI: 10.1111/ene.13260] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2016] [Accepted: 01/11/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND PURPOSE Evidence for effective treatment options for orthostatic hypotension (OH) in Parkinson's disease (PD) is scarce. Elevation of cholinergic tone with pyridostigmine bromide has been reported as a way to improve blood pressure (bp) regulation in neurogenic hypotension without causing supine hypertension. METHODS This was a double-centre, double-blind, randomized, active-control, crossover, phase II non-inferiority trial of pyridostigmine bromide for OH in PD (clinicaltrials.gov NCT01993680). Patients with confirmed OH were randomized to 14 days 3 × 60 mg/day pyridostigmine bromide or 1 × 0.2 mg/day fludrocortisone before crossover. Outcome was measured by peripheral and central bp monitoring during the Schellong manoeuvre and questionnaires. RESULTS Thirteen participants were enrolled between April 2013 and April 2015 with nine participants completing each trial arm. Repeated measures comparison showed a significant 37% improvement with fludrocortisone for the primary outcome diastolic bp drop on orthostatic challenge (baseline 22.9 ± 13.6 vs. pyridostigmine bromide 22.1 ± 17.0 vs. fludrocortisone 14.0 ± 12.6 mmHg; P = 0.04), whilst pyridostigmine bromide had no effect. Fludrocortisone caused an 11% peripheral systolic supine bp rise (baseline 128.4 ± 12.8 vs. pyridostigmine bromide 130.4 ± 18.3 vs. fludrocortisone 143.2 ± 10.1 mmHg; P = 0.01) but no central mean arterial supine bp rise (baseline 107.2 ± 7.8 vs. pyridostigmine bromide 97.0 ± 12.0 vs. fludrocortisone 107.3 ± 6.3 mmHg; P = 0.047). Subjective OH severity, motor score and quality of life remained unchanged by both study interventions. CONCLUSIONS Pyridostigmine bromide is inferior to fludrocortisone in the treatment of OH in PD. This trial provides first objective evidence of the efficacy of 0.2 mg/day fludrocortisone for OH in PD, causing minor peripheral but no central supine hypertension. In addition to peripheral bp, future trials should include central bp measurements, known to correlate more closely with cardiovascular risk.
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Affiliation(s)
- S R Schreglmann
- Department of Neurology, University Hospital Zurich, Zurich, Switzerland.,Department of Neurology, Kantonsspital St Gallen, St Gallen, Switzerland
| | - F Büchele
- Department of Neurology, University Hospital Zurich, Zurich, Switzerland
| | - M Sommerauer
- Department of Neurology, University Hospital Zurich, Zurich, Switzerland
| | - L Epprecht
- Department of Neurology, University Hospital Zurich, Zurich, Switzerland
| | - G Kägi
- Department of Neurology, Kantonsspital St Gallen, St Gallen, Switzerland
| | - S Hägele-Link
- Department of Neurology, Kantonsspital St Gallen, St Gallen, Switzerland
| | - O Götze
- Division of Gastroenterology, University Hospital Zurich, Zurich, Switzerland
| | - L Zimmerli
- Division of Internal Medicine, University Hospital Zurich, Zurich, Switzerland
| | - D Waldvogel
- Department of Neurology, University Hospital Zurich, Zurich, Switzerland
| | - C R Baumann
- Department of Neurology, University Hospital Zurich, Zurich, Switzerland
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Ramirez CE, Okamoto LE, Arnold AC, Gamboa A, Diedrich A, Choi L, Raj SR, Robertson D, Biaggioni I, Shibao CA. Efficacy of atomoxetine versus midodrine for the treatment of orthostatic hypotension in autonomic failure. Hypertension 2014; 64:1235-40. [PMID: 25185131 PMCID: PMC4231172 DOI: 10.1161/hypertensionaha.114.04225] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2014] [Accepted: 08/11/2014] [Indexed: 01/27/2023]
Abstract
The clinical presentation of autonomic failure is orthostatic hypotension. Severely affected patients require pharmacological treatment to prevent presyncopal symptoms or frank syncope. We previously reported in a proof of concept study that pediatric doses of the norepinephrine transporter blockade, atomoxetine, increases blood pressure in autonomic failure patients with residual sympathetic activity compared with placebo. Given that the sympathetic nervous system is maximally activated in the upright position, we hypothesized that atomoxetine would be superior to midodrine, a direct vasoconstrictor, in improving upright blood pressure and orthostatic hypotension-related symptoms. To test this hypothesis, we compared the effect of acute atomoxetine versus midodrine on upright systolic blood pressure and orthostatic symptom scores in 65 patients with severe autonomic failure. There were no differences in seated systolic blood pressure (means difference=0.3 mm Hg; 95% confidence [CI], -7.3 to 7.9; P=0.94). In contrast, atomoxetine produced a greater pressor response in upright systolic blood pressure (means difference=7.5 mm Hg; 95% CI, 0.6 to 15; P=0.03) compared with midodrine. Furthermore, atomoxetine (means difference=0.4; 95% CI, 0.1 to 0.8; P=0.02), but not midodrine (means difference=0.5; 95% CI, -0.1 to 1.0; P=0.08), improved orthostatic hypotension-related symptoms as compared with placebo. The results of our study suggest that atomoxetine could be a superior therapeutic option than midodrine for the treatment of orthostatic hypotension in autonomic failure.
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Affiliation(s)
- Claudia E Ramirez
- From the Department of Medicine, Division of Clinical Pharmacology and the Autonomic Dysfunction Center, Vanderbilt University School of Medicine, Nashville, Tennessee (C.E.R., L.E.O., A.C.A., A.G., A.D., S.R.R., D.R., I.B., C.A.S.); and Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee (L.C.)
| | - Luis E Okamoto
- From the Department of Medicine, Division of Clinical Pharmacology and the Autonomic Dysfunction Center, Vanderbilt University School of Medicine, Nashville, Tennessee (C.E.R., L.E.O., A.C.A., A.G., A.D., S.R.R., D.R., I.B., C.A.S.); and Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee (L.C.)
| | - Amy C Arnold
- From the Department of Medicine, Division of Clinical Pharmacology and the Autonomic Dysfunction Center, Vanderbilt University School of Medicine, Nashville, Tennessee (C.E.R., L.E.O., A.C.A., A.G., A.D., S.R.R., D.R., I.B., C.A.S.); and Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee (L.C.)
| | - Alfredo Gamboa
- From the Department of Medicine, Division of Clinical Pharmacology and the Autonomic Dysfunction Center, Vanderbilt University School of Medicine, Nashville, Tennessee (C.E.R., L.E.O., A.C.A., A.G., A.D., S.R.R., D.R., I.B., C.A.S.); and Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee (L.C.)
| | - André Diedrich
- From the Department of Medicine, Division of Clinical Pharmacology and the Autonomic Dysfunction Center, Vanderbilt University School of Medicine, Nashville, Tennessee (C.E.R., L.E.O., A.C.A., A.G., A.D., S.R.R., D.R., I.B., C.A.S.); and Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee (L.C.)
| | - Leena Choi
- From the Department of Medicine, Division of Clinical Pharmacology and the Autonomic Dysfunction Center, Vanderbilt University School of Medicine, Nashville, Tennessee (C.E.R., L.E.O., A.C.A., A.G., A.D., S.R.R., D.R., I.B., C.A.S.); and Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee (L.C.)
| | - Satish R Raj
- From the Department of Medicine, Division of Clinical Pharmacology and the Autonomic Dysfunction Center, Vanderbilt University School of Medicine, Nashville, Tennessee (C.E.R., L.E.O., A.C.A., A.G., A.D., S.R.R., D.R., I.B., C.A.S.); and Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee (L.C.)
| | - David Robertson
- From the Department of Medicine, Division of Clinical Pharmacology and the Autonomic Dysfunction Center, Vanderbilt University School of Medicine, Nashville, Tennessee (C.E.R., L.E.O., A.C.A., A.G., A.D., S.R.R., D.R., I.B., C.A.S.); and Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee (L.C.)
| | - Italo Biaggioni
- From the Department of Medicine, Division of Clinical Pharmacology and the Autonomic Dysfunction Center, Vanderbilt University School of Medicine, Nashville, Tennessee (C.E.R., L.E.O., A.C.A., A.G., A.D., S.R.R., D.R., I.B., C.A.S.); and Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee (L.C.)
| | - Cyndya A Shibao
- From the Department of Medicine, Division of Clinical Pharmacology and the Autonomic Dysfunction Center, Vanderbilt University School of Medicine, Nashville, Tennessee (C.E.R., L.E.O., A.C.A., A.G., A.D., S.R.R., D.R., I.B., C.A.S.); and Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee (L.C.).
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Vichayanrat E, Low DA, Asahina M, Owens AP, Iodice V, Galizia G, Mathias CJ. L-DOPS and the treatment of neurogenic orthostatic hypotension. FUTURE NEUROLOGY 2013. [DOI: 10.2217/fnl.13.28] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
L-threo-dihydroxyphenylserine (L-DOPS) is an oral prodrug that is converted to the sympathetic neurotransmitter noradrenaline through a single-step decarboxylation by the endogenous enzyme 3,4-dihydrophenylalanine decarboxylase. DOPS can provide an exogenous source of noradrenaline to adrenergic neurons that are involved in the maintenance of blood pressure. Impaired secretion of noradrenaline at the synaptic junction can result in neurogenic orthostatic hypotension and cause faints and falls. The safety and efficacy of DOPS has been evaluated in patients with neurogenic orthostatic hypotension caused by a variety of neurological conditions that can result in autonomic failure, such as Parkinson’s disease, multiple system atrophy, pure autonomic failure and dopamine-β-hydroxylase deficiency. In this review, we include Phase II and III clinical trials undertaken that have examined the safety, efficacy and tolerability of DOPS in the treatment of neurogenic orthostatic hypotension. Drug mechanisms and pharmacology of the drug are also discussed.
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Affiliation(s)
- Ekawat Vichayanrat
- Autonomic & Neurovascular Medicine Unit, Division of Brain Sciences, Medicine, Imperial College London at St Mary’s Hospital, Praed Street, London, W2 1NY, UK
- Autonomic Unit, National Hospital for Neurology & Neurosurgery, Queen Square, Division of Clinical Neurology, Institute of Neurology, University College London, London, UK
| | - David A Low
- Autonomic & Neurovascular Medicine Unit, Division of Brain Sciences, Medicine, Imperial College London at St Mary’s Hospital, Praed Street, London, W2 1NY, UK
- Autonomic Unit, National Hospital for Neurology & Neurosurgery, Queen Square, Division of Clinical Neurology, Institute of Neurology, University College London, London, UK
| | - Masato Asahina
- Department of Neurology, Chiba University School of Medicine, Chiba, Japan
| | - Andrew P Owens
- Autonomic & Neurovascular Medicine Unit, Division of Brain Sciences, Medicine, Imperial College London at St Mary’s Hospital, Praed Street, London, W2 1NY, UK
- Autonomic Unit, National Hospital for Neurology & Neurosurgery, Queen Square, Division of Clinical Neurology, Institute of Neurology, University College London, London, UK
| | - Valeria Iodice
- Autonomic & Neurovascular Medicine Unit, Division of Brain Sciences, Medicine, Imperial College London at St Mary’s Hospital, Praed Street, London, W2 1NY, UK
- Autonomic Unit, National Hospital for Neurology & Neurosurgery, Queen Square, Division of Clinical Neurology, Institute of Neurology, University College London, London, UK
| | - Gianluigi Galizia
- Division of Physical Medicine & Rehabilitation, Salvatore Maugeri Foundation, IRCCS, Scientific Institute of Veruno, Veruno (NO), Italy
| | - Christopher J Mathias
- Autonomic Unit, National Hospital for Neurology & Neurosurgery, Queen Square, Division of Clinical Neurology, Institute of Neurology, University College London, London, UK
- Autonomic & Neurovascular Medicine Unit, Division of Brain Sciences, Medicine, Imperial College London at St Mary’s Hospital, Praed Street, London, W2 1NY, UK.
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Marinoni M, Ginanneschi A, Inzitari D, Mannelli M, Modesti P, Amaducci L. Impaired cerebral autoregulation in patients with shy-drager syndrome. Int J Angiol 2011. [DOI: 10.1007/bf02651555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Goldstein DS, Holmes C, Sewell L, Kopin IJ. Hypertension increases cerebral 6-18F-fluorodopa-derived radioactivity. J Nucl Med 2009; 50:1479-82. [PMID: 19690020 DOI: 10.2967/jnumed.109.062869] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
UNLABELLED 6-(18)F-fluorodopa PET depicts the striatal dopaminergic lesion characterizing Parkinson disease (PD); however, striatal uptake of 6-(18)F-fluorodopa-derived radioactivity can be normal. Supine hypertension (SH) might increase 6-(18)F-fluorodopa uptake. METHODS We measured putamen, caudate, and occipital cortex 6-(18)F-fluorodopa-derived radioactivity and supine blood pressure in patients with PD + SH (systolic pressure >/= 180 mm Hg, n = 8), patients with PD without SH (PD - SH, n = 19), patients with pure autonomic failure (n = 8), and controls (n = 16). RESULTS Peak putamen radioactivity correlated with supine systolic pressure across all subjects and among PD patients and was higher in PD + SH than in PD - SH (P = 0.01). Both subgroups had rapid fractional declines in radioactivity between the peak and late values (P < 0.0001, compared with controls). Arterial 6-(18)F-fluorodopa concentrations were similar in the compared groups. CONCLUSION In PD, SH is associated with augmented striatal 6-(18)F-fluorodopa-derived radioactivity. Regardless of SH, retention of 6-(18)F-fluorodopa-derived radioactivity is markedly reduced. A model-independent approach can identify striatal dopaminergic denervation in PD.
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Affiliation(s)
- David S Goldstein
- Clinical Neurocardiology Section, Clinical Neurosciences Program, Division of Intramural Research, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland, USA.
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12
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An inverted seated posture decreases elbow flexion force and muscle activation. Eur J Appl Physiol 2009; 106:139-47. [PMID: 19214555 DOI: 10.1007/s00421-009-0999-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/21/2009] [Indexed: 10/21/2022]
Abstract
The purpose of this study was to determine if discrepancies exist between upright and inverted seated positions in isometric maximal voluntary contraction (MVC) elbow flexor force, MVC force produced in the first 100 ms (F100), MVC rate of force development, electromyographic (EMG) activity of the biceps and triceps as well as heart rate and blood pressure. The results showed significantly (p < 0.01) higher MVC force (543.6 +/- 29.6 vs. 486.5 +/- 23.0 N), F100 (328.3 +/- 94.5 vs. 274.6 +/- 101.8 N), rate of force development (p = 0.003) (1,851.9 +/- 742.2 vs. 1,591.0 +/- 719.6 N s(-1)) and biceps brachii EMG activity (48%, p < 0.01) in the upright versus inverted condition. There were relatively greater co-contractions with the inverted position (p < 0.01) due to the lack of change in triceps' EMG and the substantial decrease in biceps' EMG. There were no significant changes in trunk EMG activity. With inversion, there were significant decreases in heart rate (16.8%), systolic (11.6%) and diastolic (12.1%) blood pressures (p < 0.0001). These results illustrate decrements in neuromuscular performance with an inverted seated posture which may be related to an altered sympathetic response.
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Abstract
L-threo-3,4-dihydroxyphenylserine (L-DOPS, droxydopa) is a synthetic catecholamino acid. When taken orally, L-DOPS is converted to the sympathetic neurotransmitter, norepinephrine (NE), via decarboxylation catalyzed by L-aromatic-amino-acid decarboxylase (LAAAD). Plasma L-DOPS levels peak at about 3 h, followed by a monoexponential decline with a half-time of 2 to 3 h. Plasma levels of NE and of its main neuronal metabolite, dihydroxyphenylglycol (DHPG) peak approximately concurrently but at much lower concentrations. The relatively long half-time for disappearance of L-DOPS from plasma, compared to that of NE, explains their very different attained plasma concentrations. In patients with neurogenic orthostatic hypotension, L-DOPS increases blood pressure and ameliorates orthostatic intolerance. Inhibition of LAAAD, such as by treatment with carbidopa, which does not penetrate the blood-brain barrier, prevents the blood pressure effects of the drug, indicating that L-DOPS increases blood pressure by augmenting NE production outside the brain. Patients with pure autonomic failure (which usually entails loss of sympathetic noradrenergic nerves), and patients with multiple system atrophy (in which noradrenergic innervation remains intact) have similar plasma NE responses to L-DOPS. This suggests mainly non-neuronal production of NE from L-DOPS. L-DOPS is very effective in treatment of deficiency of dopamine-beta-hydroxylase (DBH), the enzyme required for conversion of dopamine to NE in sympathetic nerves. L-DOPS holds promise for treating other much more common conditions involving decreased DBH activity or NE deficiency, such as a variety of syndromes associated with neurogenic orthostatic hypotension.
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Affiliation(s)
- David S Goldstein
- Clinical Neurocardiology Section, National Institute of Neurological Disorders and Stroke, National Institutes of Health, USA.
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Lamarre-Cliche M. Drug treatment of orthostatic hypotension because of autonomic failure or neurocardiogenic syncope. Am J Cardiovasc Drugs 2004; 2:23-35. [PMID: 14727996 DOI: 10.2165/00129784-200202010-00004] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Orthostatic hypotension either because of autonomic failure or neurocardiogenic syncope can be very incapacitating and should be treated accordingly. Drug therapy is frequently needed to alleviate orthostatic symptoms. The physiopathological basis of neurocardiogenic syncope and of autonomic failure is completely different and their treatment should be distinct. In the past 5 years, many randomized, placebo-controlled trials have shed light on the efficacy of specific pressor drugs. In patients with orthostatic hypotension because of autonomic failure, alpha-adrenoceptor agonists, and midodrine in particular, have been shown to increase standing blood pressure and decrease orthostatic symptoms. Other drugs such as octreotide, indomethacin or ergotamine have also been shown to elevate standing blood pressure and/or orthostatic tolerance. Fludrocortisone is a well known and frequently used pressor drug but randomized controlled studies are needed to measure its efficacy. In patients with orthostatic hypotension associated with neurocardiogenic syncope, clinical trials have demonstrated that beta-blockers, especially beta(1)-selective agents without intrinsic sympathomimetic activity such as atenolol, midodrine and paroxetine can decrease recurrence of syncope. Treatment algorithms, such as those presented in this review, should always be interpreted in the light of individual patient characteristics. Many of the drugs used for orthostatic hypotension have multiple indications and contraindications that should influence therapeutic decisions. Little is known about the effectiveness and tolerability of specific combinations of pressor drugs. Consequently, sound clinical judgment and close follow-up of patients should always guide combination therapy.
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Hussain RM, McIntosh SJ, Lawson J, Kenny RA. Fludrocortisone in the treatment of hypotensive disorders in the elderly. Heart 1996; 76:507-9. [PMID: 9014799 PMCID: PMC484603 DOI: 10.1136/hrt.76.6.507] [Citation(s) in RCA: 67] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVE To evaluate tolerance of fludrocortisone in older patients with hypotensive disorders. DESIGN Prospective case series. SETTING Syncope clinic. PATIENTS 64 Consecutive patients over 65 years (mean age 80 years) with one or more hypotensive disorders (orthostatic hypotension, vasodepressor carotid sinus syncope, and/or vasodepressor neurocardiogenic syncope. INTERVENTIONS Fludrocortisone in daily doses of 100 micrograms [corrected] (72%), 50 micrograms [corrected] (27%), and 200 micrograms [corrected] (one patient). MAIN OUTCOME MEASURES Adverse events, treatment withdrawal. RESULTS During follow up 13 patients died of unrelated causes. Of the remainder 33% discontinued fludrocortisone at a mean of five months. Reasons for discontinuing treatment were hypertension, five; cardiac failure, four; depression, three; oedema, three; and unspecified, two. In those who continued treatment supine systolic and diastolic blood pressure did not differ significantly from baseline (follow up two to 21 months). Hypokalaemia developed in 24% at a mean of eight months; in no case was treatment withdrawn because of hypokalaemia. CONCLUSION Fludrocortisone, even in low doses, is poorly tolerated in the long term in older patients with hypotensive disorders.
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Affiliation(s)
- R M Hussain
- Cardiovascular Investigation Unit, Royal victoria Infirmary, Newcastle upon Tyne
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Abstract
This review focuses on the actual limits of the clinical pharmacology of drugs used for the treatment of orthostatic hypotension. The evidences for heterogeneity of the pathophysiological mechanisms of primary orthostatic hypotension and autonomic failure are discussed. The available data on the efficacy of some drugs used in orthostatic hypotension are also discussed.
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Affiliation(s)
- J M Senard
- Laboratoire de Pharmacologie Médicale et Clinique, INSERM U317, Faculté de Médecine, Toulouse, France
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Warkentin S, Passant U, Minthon L, Karlson S, Edvinsson L, Fäldt R, Gustafson L, Risberg J. Redistribution of blood flow in the cerebral cortex of normal subjects during head-up postural change. Clin Auton Res 1992; 2:119-24. [PMID: 1638106 DOI: 10.1007/bf01819667] [Citation(s) in RCA: 30] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Regional cerebral blood flow was measured in 21 normotensive subjects during supine rest and during head-up tilt to 70 degrees. The results showed significant and consistent regional cerebral blood flow changes in the frontal areas with lower relative flow distribution values (percentage of mean flow) during head-up tilt than during supine rest. The lower frontal flow distribution values during tilt were not related to habituation, to repeated measurements, or to the estimated level of arterial CO2 which was derived from expired end-tidal CO2 levels. None of the subjects had orthostatic hypotension and there was no significant difference in mean hemispheric blood flow between lying down and standing up. There was no significant gender difference in regional cerebral blood flow, although female subjects tended to have higher mean hemispheric flow than males in both postures. It remains to be established whether the flow decreases in the frontal cortex are caused by cerebral functional factors or by haemodynamic mechanisms.
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Affiliation(s)
- S Warkentin
- Department of Psychogeriatrics, University Hospital, Lund, Sweden
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