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Chen YH, Chen CT. Atomoxetine for Intradialytic Hypotension in a Patient on Hemodialysis: A Case Report. Kidney Med 2024; 6:100840. [PMID: 38947771 PMCID: PMC11214336 DOI: 10.1016/j.xkme.2024.100840] [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] [Indexed: 07/02/2024] Open
Abstract
Intradialytic hypotension significantly affects patient safety and clinical outcomes during hemodialysis. Despite various pharmacological and nonpharmacological interventions, effective management remains elusive. In this report, we detail a case of intradialytic hypotension in a male patient in his 40s, undergoing hemodialysis with a history of polycystic kidney disease. Eight years ago, the patient underwent bilateral nephrectomy because of a severe cystic infection, after which his systolic blood pressure (BP) persistently remained at 50-70 mm Hg during dialysis sessions. The initial treatment strategy for hypotension included fludrocortisone, midodrine, and prednisolone, leading to a slight temporary increase in BP, which subsequently declined. As the patient's condition deteriorated, the administration of norepinephrine or dopamine became necessary to sustain BP during dialysis. Given the patient's resistance to these treatments, a daily dose of 25 mg of atomoxetine was introduced. Following this treatment, there was a gradual improvement in the patient's vertigo, weakness, and BP. This case illustrates that low-dose atomoxetine can alleviate symptoms and elevate BP in patients experiencing severe intradialytic hypotension during hemodialysis.
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Affiliation(s)
- Yi-Hsin Chen
- Department of Nephrology, Taichung Tzu Chi Hospital, Taichung, Taiwan
- School of Medicine, Tzu Chi University, Hualien, Taiwan
- Department of Artificial Intelligence and Data Science, National Chung Hsing University, Taichung, Taiwan
| | - Chih-Tsung Chen
- Department of Nephrology, Taichung Tzu Chi Hospital, Taichung, Taiwan
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Mwesigwa N, Shibao CA. Norepinephrine Reuptake Inhibition, an Emergent Treatment for Neurogenic Orthostatic Hypotension. Hypertension 2024; 81:1460-1466. [PMID: 38766862 PMCID: PMC11168875 DOI: 10.1161/hypertensionaha.124.22069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
The NET (norepinephrine transporter) is situated in the prejunctional plasma membrane of noradrenergic neurons. It is responsible for >90% of the norepinephrine uptake that is released in the autonomic neuroeffector junction. Inhibitors of this cell membrane transporter, known as norepinephrine reuptake inhibitors (NRIs), are commercially available for the treatment of depression and attention deficit hyperactivity disorder. These agents increase norepinephrine levels, potentiating its action in preganglionic and postganglionic adrenergic neurons, the latter through activation of α-1 adrenoreceptors. Previous studies found that patients with neurogenic orthostatic hypotension can improve standing blood pressure and reduce symptoms of neurogenic orthostatic hypotension after a single administration of the selective NRI atomoxetine. This effect was primarily observed in patients with impaired central autonomic pathways with otherwise normal postganglionic sympathetic fibers, known as multiple system atrophy. Likewise, patients with normal or high norepinephrine levels may benefit from NRIs. The long-term efficacy of NRIs for the treatment of neurogenic orthostatic hypotension-related symptoms is currently under investigation. In summary, an in-depth understanding of the pathophysiology of neurogenic orthostatic hypotension resulted in the discovery of a new therapeutic pathway targeted by NRI.
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Affiliation(s)
- Naome Mwesigwa
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN (N.M., C.A.S.)
| | - Cyndya A Shibao
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN (N.M., C.A.S.)
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Baughman DJ, Watson CM, Beich JW, Herboso MNJ, Cuttie LK, Marlyne ABC. Recommendation for Long-term Management of Adult Attention-Deficit/Hyperactivity Disorder in Military Populations, Veterans, and Dependents: A Narrative Review. Mil Med 2024; 189:e1343-e1352. [PMID: 37878798 DOI: 10.1093/milmed/usad403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 07/11/2023] [Accepted: 09/28/2023] [Indexed: 10/27/2023] Open
Abstract
INTRODUCTION In addition to the higher burden of mental health disease in the military, there is a compounding antecedent association between behavioral health comorbidities and the treatment of attention-deficit/hyperactivity disorder (ADHD) in this population. Despite the low prevalence of new-onset ADHD in adults globally, the rate of stimulant (i.e., amphetamines) prescription is increasing. Stimulants can exacerbate mental health disease (often masquerading as ADHD symptomatology), precluding optimal treatment of the underlying etiology and imposing unnecessary dangerous side effects. This study aimed to evaluate the long-term safety and efficacy of stimulants for managing adult ADHD. METHODS A nine-member multidisciplinary team reviewed a PubMed search with the terms "adult," "ADHD," and "stimulant." Targeted PubMed and Google Scholar searches for "adult ADHD" paired with Food and Drug Administration -approved ADHD medications and Google Scholar literature using forward and reverse snowballing methods were performed for high-quality studies focusing on long-term treatment in ADHD. An evidence table and clinical algorithm were developed from the review. RESULTS Of the 1,039 results, 50 articles were fully reviewed, consisting of 21 descriptive and experimental studies, 18 observational, and 11 systematic reviews and meta-analyses. Illustrative cases within the structured discussion of the results highlighted ADHD and psychiatric comorbidities, risks, harms, and benefits of stimulant use, medication mechanisms of action, and limitations of the current evidence. DISCUSSION The dearth of high-quality studies on long-term ADHD management in adults fails to establish a causal relationship between stimulant use and physiological harm. Despite mixed evidence supporting the benefit of stimulants, there is clear evidence regarding the risk of harm. The serious risks of stimulants include arrhythmias, myocardial infarction, stroke/transient ischemic attack, sudden death, psychosis, and worsening of behavioral health disease. Additionally, there is a possible long-term risk of harm due to chronic sympathetic load (i.e., cardiovascular system remodeling). Stimulants pose a greater risk for addiction and abuse compared to other evidence-based nonstimulant medications that have similar effectiveness. Both stimulants and nonstimulants might promote favorable neuroanatomical changes for long-term improvement of ADHD symptoms, but nonstimulants (atomoxetine) have the pharmacological advantage of also mitigating the effects of sympathetic load (sympatholysis) and anxiety (anxiolysis). Given the physiological uncertainty of extended stimulant use for adults, especially older adults with vulnerable cardiovascular systems, clinicians should proceed cautiously when considering initiating or sustaining stimulant therapy. For long-term treatment of ADHD in adults, clinicians should consider nonstimulant alternatives (including behavioral therapy) due to the comparatively lower side effect risk and the possible additional benefit in patients with behavioral health comorbidities. CONCLUSION Long-term safety of stimulant use for adults with ADHD is uncertain, as existing studies are limited in quality and duration. This is particularly important for military populations with higher rates of mental health conditions. Managing ADHD and related conditions requires prioritizing cardiovascular safety, especially for older adults. Nonstimulant options can be helpful, especially in comorbid psychiatric disease. Before treating ADHD, ruling out and controlling other behavioral health conditions is essential to avoid masking or worsening underlying issues and reducing unnecessary medication side effects.
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Affiliation(s)
- Derek J Baughman
- Medical Director-Primary Care, Barksdale AFB, 2nd Medical Group, Barksdale AFB, LA 71110, USA
| | - Crista M Watson
- Physician Assistant-Family Health, Barksdale AFB, 2nd Medical Group, Barksdale AFB, LA 71110, USA
| | - Jonathan W Beich
- Psychiatrist/MH Element Chief-Behavioral Health, Barksdale AFB, 2nd Medical Group, Barksdale AFB, LA 71110, USA
| | - May N Joresa Herboso
- Aerospace Medical Technician-Primary Care, Barksdale AFB, 2nd Medical Group, Barksdale AFB, LA 71110, USA
| | - Liana K Cuttie
- Nurse Practitioner, Family Health-Primary Care, Barksdale AFB, 2nd Medical Group, Barksdale AFB, LA 71110, USA
| | - Ari-Beth C Marlyne
- Chief of Medical Staff & Family Medicine Physician, Barksdale AFB, 2nd Medical Group, Barksdale AFB, LA 71110, USA
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Shibao CA, Harrison DG, Biaggioni I. David Herlie Robertson, MD. Hypertension 2024; 81:e44-e46. [PMID: 38630798 DOI: 10.1161/hypertensionaha.124.22755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Affiliation(s)
- Cyndya A Shibao
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - David G Harrison
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Italo Biaggioni
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
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Biaggioni I, Arnold AC, Black B, Diedrich A, Furlan R, Gamboa A, Garland E, Jacob G, Jordan J, Okamoto LE, Raj SR, Sato K, Shannon J, Tank J, Peltier A, Shibao CA. In memoriam: a celebration of the autonomic contributions of David Robertson (1947-2024). Clin Auton Res 2024; 34:5-7. [PMID: 38436914 DOI: 10.1007/s10286-024-01025-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 01/25/2024] [Indexed: 03/05/2024]
Affiliation(s)
- Italo Biaggioni
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, 37232, USA.
| | - Amy C Arnold
- Department of Neural and Behavioral Sciences, Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Bonnie Black
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, 37232, USA
| | - Andre Diedrich
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, 37232, USA
| | - Raffaello Furlan
- Internal Medicine and Syncope Unit, Humanitas Research Hospital, Humanitas University, Rozzano, Italy
| | - Alfredo Gamboa
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, 37232, USA
| | - Emily Garland
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, 37232, USA
| | - Giris Jacob
- Deparment of Internal Medicine, Recanati Autonomic Dysfunction Center, Sourasky Medical Center and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jens Jordan
- Institute of Aerospace Medicine, German Aerospace Center and Medical Faculty, University of Cologne, Cologne, Germany
| | - Luis E Okamoto
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, 37232, USA
| | - Satish R Raj
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, 37232, USA
- Department of Cardiac Sciences, Cumming School of Medicine, Libin Cardiovascular Institute, University of Calgary, Calgary, Canada
| | - Kyoko Sato
- Adachi Medical Center, Tokyo Women's Medical University, Tokyo, Japan
| | | | - Jens Tank
- Institute of Aerospace Medicine, German Aerospace Center and Medical Faculty, University of Cologne, Cologne, Germany
| | - Amanda Peltier
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, 37232, USA
| | - Cyndya A Shibao
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, 37232, USA
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Srinivas V, Choubey U, Kapparath S, Shaik T, Singh B, Mahmood R, Garg N, Aggarwal P, Jain R. Age-Related Orthostatic Hypotension: A Comprehensive Analysis of Prevalence, Mechanisms, and Management in the Geriatric Population. Cardiol Rev 2024:00045415-990000000-00186. [PMID: 38189438 DOI: 10.1097/crd.0000000000000636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2024]
Abstract
Geriatric patients frequently encounter orthostatic hypotension (OH), a multifaceted condition characterized by a significant drop in blood pressure upon assuming an upright position. As the elderly population is particularly susceptible to OH, our review endeavors to comprehensively explore the complex nature of this condition and various factors contributing to its development. We investigate the impact of comorbidities, polypharmacy, age-related physiological changes, and autonomic dysfunction in the pathogenesis of OH. Geriatric patients with OH are faced with an elevated risk of falls, syncope, a decline in their overall quality of life, and hence increased mortality. These implications require careful consideration, necessitating a thorough examination of therapeutic strategies. We evaluate various pharmaceutical and nonpharmacological therapies, delving into the effectiveness and safety of each approach in managing OH within geriatric populations. We explore the role of pharmacotherapy in alleviating symptoms and mitigating OH-related complications, as well as the potential benefits of volume expansion techniques to augment blood volume and stabilize blood pressure. We place particular emphasis on the significance of lifestyle changes and nonpharmacological interventions in enhancing OH management among the elderly. These interventions encompass dietary modifications, regular physical activity, and postural training, all tailored to the unique needs of the individual patient. To optimize outcomes and ensure patient safety, we underscore the importance of individualized treatment plans that take into account the geriatric patient's overall health status, existing comorbidities, and potential interactions with other medications. This review aims to improve clinical practice and patient outcomes by advocating for early detection, properly tailored management, and targeted interventions to address OH in the elderly population. By raising awareness of OH's prevalence and complexities among healthcare professionals, we hope to foster a comprehensive understanding of OH and contribute to the overall wellness and quality of life of this vulnerable demographic.
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Affiliation(s)
- Varsha Srinivas
- From the PES Institute of Medical Sciences and Research, India
| | | | | | - Tanveer Shaik
- Avalon University School Of Medicine, Willemstad, Curacao
| | | | - Ramsha Mahmood
- Avalon University School Of Medicine, Willemstad, Curacao
| | - Nikita Garg
- Children's Hospital of Michigan, Detroit, MI
| | - Priyanka Aggarwal
- Maharishi Markandeshwar Institute of Medical Science & Research, Mullana, Haryana, India
| | - Rohit Jain
- Department of Internal Medicine, Penn State Health Milton S. Hershey Medical Center, Hershey, PA
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Chen B, Yang W, Luo Y, Tan EK, Wang Q. Non-pharmacological and drug treatment of autonomic dysfunction in multiple system atrophy: current status and future directions. J Neurol 2023; 270:5251-5273. [PMID: 37477834 DOI: 10.1007/s00415-023-11876-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 07/11/2023] [Accepted: 07/11/2023] [Indexed: 07/22/2023]
Abstract
Multiple system atrophy (MSA) is a sporadic, fatal, and rapidly progressive neurodegenerative disease of unknown etiology that is clinically characterized by autonomic failure, parkinsonism, cerebellar ataxia, and pyramidal signs in any combination. Early onset and extensive autonomic dysfunction, including cardiovascular dysfunction characterized by orthostatic hypotension (OH) and supine hypertension, urinary dysfunction characterized by overactive bladder and incomplete bladder emptying, sexual dysfunction characterized by sexual desire deficiency and erectile dysfunction, and gastrointestinal dysfunction characterized by delayed gastric emptying and constipation, are the main features of MSA. Autonomic dysfunction greatly reduces quality of life and increases mortality. Therefore, early diagnosis and intervention are urgently needed to benefit MSA patients. In this review, we aim to discuss the systematic treatment of autonomic dysfunction in MSA, and focus on the current methods, starting from non-pharmacological methods, such as patient education, psychotherapy, diet change, surgery, and neuromodulation, to various drug treatments targeting autonomic nerve and its projection fibers. In addition, we also draw attention to the interactions among various treatments, and introduce novel methods proposed in recent years, such as gene therapy, stem cell therapy, and neural prosthesis implantation. Furthermore, we elaborate on the specific targets and mechanisms of action of various drugs. We would like to call for large-scale research to determine the efficacy of these methods in the future. Finally, we point out that studies on the pathogenesis of MSA and pathophysiological mechanisms of various autonomic dysfunction would also contribute to the development of new promising treatments and concepts.
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Affiliation(s)
- BaoLing Chen
- Department of Neurology, Zhujiang Hospital, Southern Medical University, Gongye Road 253, Guangzhou, 510282, Guangdong, People's Republic of China
| | - Wanlin Yang
- Department of Neurology, Zhujiang Hospital, Southern Medical University, Gongye Road 253, Guangzhou, 510282, Guangdong, People's Republic of China
| | - Yuqi Luo
- Department of Neurology, Zhujiang Hospital, Southern Medical University, Gongye Road 253, Guangzhou, 510282, Guangdong, People's Republic of China
| | - Eng-King Tan
- Department of Neurology, National Neuroscience Institute, Singapore General Hospital, Singapore, Singapore.
- Duke-NUS Medical School, Singapore, Singapore.
| | - Qing Wang
- Department of Neurology, Zhujiang Hospital, Southern Medical University, Gongye Road 253, Guangzhou, 510282, Guangdong, People's Republic of 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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Jung YJ, Kim A, Okamoto LE, Hong WH. Effects of Atomoxetine for the Treatment of Neurogenic Orthostatic Hypotension in Patients With Alpha-synucleinopathies: A Systematic Review of Randomized Controlled Trials and a Focus-Group Discussion. J Clin Neurol 2023; 19:165-173. [PMID: 36647224 PMCID: PMC9982187 DOI: 10.3988/jcn.2022.0018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Revised: 08/03/2022] [Accepted: 08/03/2022] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND AND PURPOSE Neurogenic orthostatic hypotension (nOH) is one of the most important nonmotor symptoms in patients with α-synucleinopathies. Atomoxetine is a selective norepinephrine transporter blocker that is a treatment option for nOH. This systematic review and expert focus-group study was designed to obtain evidence from published data and clinical experiences of Korean movement-disorder specialists about the efficacy and safety of atomoxetine for the pharmacological treatment of nOH in patients with α-synucleinopathies. METHODS The study comprised a systematic review and a focus-group discussion with clinicians. For the systematic review, multiple comprehensive databases including MEDLINE, Embase, Cochrane Library, CINAHL, PsycInfo, and KoreaMed were searched to retrieve articles that assessed the outcomes of atomoxetine therapy. A focus-group discussion was additionally performed to solicit opinions from experts with experience in managing nOH. RESULTS The literature review process yielded only four randomized controlled trials on atomoxetine matching the inclusion criteria. Atomoxetine effectively increased systolic blood pressure and improved OH-related symptoms as monotherapy or in combination with other drugs. Its effects were pronounced in cases with central autonomic failure, including multiple-system atrophy (MSA). Atomoxetine might be a safe monotherapy regarding the risk of supine hypertension. CONCLUSIONS Atomoxetine is an effective and safe option for short-term nOH management, which could be more evident in patients with central autonomic dysfunction such as MSA. However, there is a paucity of evidence in the literature, and data from the focus-group discussion were inadequate, and so further investigation is warranted.
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Affiliation(s)
- Yu Jin Jung
- Department of Neurology, Daejeon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Aryun Kim
- Department of Neurology, Chungbuk National University Hospital, Cheongju, Korea
| | - Luis E. Okamoto
- Department of Medicine, Division of Clinical Pharmacology and the Autonomic Dysfunction Center, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Woi-Hyun Hong
- College of Medicine and Medical Research Information Center (MedRIC), Chungbuk National University, Cheongju, Korea.
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10
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How to unblur the vasovagal evidence? Clin Auton Res 2023; 33:5-7. [PMID: 36538152 DOI: 10.1007/s10286-022-00915-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 12/05/2022] [Indexed: 12/24/2022]
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Redding ZV, Sabol KE. Reduced attentional lapses in male rats following a combination treatment of low-dose D-serine and atomoxetine. J Psychopharmacol 2023; 37:204-215. [PMID: 36648101 DOI: 10.1177/02698811221149652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Goal-directed attention involves the selective processing of behaviorally relevant sensory information. This selective processing is thought to be supported by glutamatergic and noradrenergic systems. Pharmacotherapies that simultaneously target these systems could therefore be effective treatments for impaired attention. AIMS We first tested an N-methyl-D-aspartate (NMDA) receptor co-agonist (D-serine) for effects on attention (processing speed and attentional lapses). NMDA receptor activation is thought to support noradrenergic effects on sensory processing; therefore, we tested a combination treatment comprising D-serine and a norepinephrine reuptake inhibitor (atomoxetine). METHODS D-serine was first tested in rats performing a two-choice visuospatial discrimination task. Combination treatments comprising relatively low doses of D-serine and atomoxetine were then tested in a separate group. RESULTS In experiment 1, D-serine reduced the skew of initiation time (IT) distributions (IT devmode) at the highest dose tested (300 mg/kg). In experiment 2, low-dose D-serine (125 mg/kg) had no effect, while low-dose atomoxetine (0.3 mg/kg) reduced IT devmode and slowed movement speed. Importantly, the combination of these relatively low doses of D-serine and atomoxetine reduced IT devmode more than either drug alone without further slowing movement speed. CONCLUSIONS IT devmode is thought to reflect attentional lapses; therefore, D-serine's effects on IT devmode suggest that NMDA receptors are involved in the preparatory deployment of attention. Greater effects following a combination of D-serine and atomoxetine suggest that preparatory attention can be facilitated by targeting glutamatergic and noradrenergic systems simultaneously. These results could inform the development of improved treatments for individuals with ADHD who experience abnormally high attentional lapses.
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Affiliation(s)
- Zach V Redding
- Department of Psychology, The University of Mississippi, University Park, MS, USA.,Department of Neuroscience, University of Rochester Medical Center, Rochester, NY, USA
| | - Karen E Sabol
- Department of Psychology, The University of Mississippi, University Park, MS, USA
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Fedorowski A, Ricci F, Hamrefors V, Sandau KE, Chung TH, Muldowney JAS, Gopinathannair R, Olshansky B. Orthostatic Hypotension: Management of a Complex, But Common, Medical Problem. Circ Arrhythm Electrophysiol 2022; 15:e010573. [PMID: 35212554 PMCID: PMC9049902 DOI: 10.1161/circep.121.010573] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Orthostatic hypotension (OH), a common, often overlooked, disorder with many causes, is associated with debilitating symptoms, falls, syncope, cognitive impairment, and risk of death. Chronic OH, a cardinal sign of autonomic dysfunction, increases with advancing age and is commonly associated with neurodegenerative and autoimmune diseases, diabetes, hypertension, heart failure, and kidney failure. Management typically involves a multidisciplinary, patient-centered, approach to arrive at an appropriate underlying diagnosis that is causing OH, treating accompanying conditions, and providing individually tailored pharmacological and nonpharmacological treatment. We propose a novel streamlined pathophysiological classification of OH; review the relationship between the cardiovascular disease continuum and OH; discuss OH-mediated end-organ damage; provide diagnostic and therapeutic algorithms to guide clinical decision making and patient care; identify current gaps in knowledge and try to define future research directions. Using a case-based learning approach, specific clinical scenarios are presented highlighting various presentations of OH to provide a practical guide to evaluate and manage patients who have OH.
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Affiliation(s)
- Artur Fedorowski
- Dept of Clinical Sciences, Lund University, Malmö
- Dept of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Fabrizio Ricci
- Dept of Clinical Sciences, Lund University, Malmö
- Dept of Neuroscience, Imaging & Clinical Sciences, “G.d’Annunzio” University, Chieti-Pescara
- Casa di Cura Villa Serena, Città Sant’Angelo, Italy
| | - Viktor Hamrefors
- Dept of Clinical Sciences, Lund University, Malmö
- Dept of Internal Medicine, Skåne University Hospital, Malmö, Sweden
| | | | - Tae Hwan Chung
- Dept of Physical Medicine & Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD
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New approaches to treatments for sleep, pain and autonomic failure in Parkinson's disease - Pharmacological therapies. Neuropharmacology 2022; 208:108959. [PMID: 35051446 DOI: 10.1016/j.neuropharm.2022.108959] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Revised: 01/08/2022] [Accepted: 01/13/2022] [Indexed: 01/07/2023]
Abstract
Non-motor symptoms (NMSs) are highly prevalent throughout the course of Parkinson's disease (PD). Pain, autonomic dysfunction and sleep disturbances remain at the forefront of the most common NMSs; their treatment is challenging and their effect on the quality of life of both patients and caregivers detrimental. Yet, the landscape of clinical trials in PD is still dominated by therapeutic strategies seeking to ameliorate motor symptoms; subsequently, effective strategies to successfully treat NMSs remain a huge unmet need. Wider awareness among industry and researchers is thus essential to give rise to development and delivery of high-quality, large-scale clinical trials in enriched populations of patients with PD-related pain, autonomic dysfunction and sleep. In this review, we discuss recent developments in the field of pharmacological treatment strategies designed or re-purposed to target three key NMSs: pain, autonomic dysfunction and sleep disturbances. We focus on emerging evidence from recent clinical trials and outline some exciting and intriguing findings that call for further investigations.
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Lamotte G, Sandroni P. Updates on the Diagnosis and Treatment of Peripheral Autonomic Neuropathies. Curr Neurol Neurosci Rep 2022; 22:823-837. [PMID: 36376534 PMCID: PMC9663281 DOI: 10.1007/s11910-022-01240-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/05/2022] [Indexed: 11/16/2022]
Abstract
PURPOSE OF REVIEW Autonomic neuropathies are a complex group of disorders and result in diverse clinical manifestations that affect the cardiovascular, gastrointestinal, urogenital, and sudomotor systems. We focus this review on the diagnosis and treatment of peripheral autonomic neuropathies. We summarize the diagnostic tools and current treatment options that will help the clinician care for individuals with peripheral autonomic neuropathies. RECENT FINDINGS Autonomic neuropathies occur often in conjunction with somatic neuropathies but they can also occur in isolation. The autonomic reflex screen is a validated tool to assess sympathetic postganglionic sudomotor, cardiovascular sympathetic noradrenergic, and cardiac parasympathetic (i.e., cardiovagal) function. Initial laboratory evaluation for autonomic neuropathies includes fasting glucose or oral glucose tolerance test, thyroid function tests, kidney function tests, vitamin-B12, serum, and urine protein electrophoresis with immunofixation. Other laboratory tests should be guided by the clinical context. Reduced intraepidermal nerve density on skin biopsy is a finding, not a diagnosis. Skin biopsy can be helpful in selected individuals for the diagnosis of disorders affecting small nerve fibers; however, we strongly discourage the use of skin biopsy without clinical-physiological correlation. Ambulatory blood pressure monitoring may lead to early identification of patients with cardiovascular autonomic neuropathy in the primary care setting. Disease-modifying therapies should be used when available in combination with nonpharmacological management and symptomatic pharmacologic therapies. Autonomic function testing can guide the therapeutic decisions and document improvement with treatment. A systematic approach guided by the autonomic history and standardized autonomic function testing may help clinicians when identifying and/or counseling patients with autonomic neuropathies. Treatment should be individualized and disease-modifying therapies should be used when available.
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Affiliation(s)
- Guillaume Lamotte
- Department of Neurology, University of Utah, Salt Lake City, UT, USA.
| | - Paola Sandroni
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
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15
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Lamotte G, Millar Vernetti P. Inhibition of the norepinephrine transporter to treat neurogenic orthostatic hypotension: is this the end of the story? Clin Auton Res 2021; 31:645-647. [PMID: 34757507 DOI: 10.1007/s10286-021-00839-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Guillaume Lamotte
- Department of Neurology, University of Utah, Salt Lake City, UT, USA.
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Kaufmann H, Vickery R, Wang W, Kanodia J, Shibao CA, Norcliffe-Kaufmann L, Haumann B, Biaggioni I. Safety and efficacy of ampreloxetine in symptomatic neurogenic orthostatic hypotension: a phase 2 trial. Clin Auton Res 2021; 31:699-711. [PMID: 34657222 PMCID: PMC8629777 DOI: 10.1007/s10286-021-00827-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 09/08/2021] [Indexed: 12/13/2022]
Abstract
PURPOSE In neurogenic orthostatic hypotension, blood pressure falls when upright owing to impaired release of norepinephrine, leading to dizziness. Ampreloxetine, a selective norepinephrine reuptake inhibitor, increases circulating norepinephrine levels. This study explored the safety of ampreloxetine and its effect on blood pressure and symptoms in patients with neurogenic orthostatic hypotension. METHODS A multicenter ascending-dose trial (range 1-20 mg, Part A) was followed by a 1 day, double-blind, randomized, placebo-controlled study (median dose 15 mg, Part B). Eligible patients then enrolled in a 20-week, open-label, steady-state extension phase (median dose 10 mg, Part C) followed by a 4-week withdrawal. Assessments included the Orthostatic Hypotension Symptom Assessment Scale (item 1), supine/seated/standing blood pressure, and safety. RESULTS Thirty-four patients (age 66 ± 8 years, 22 men) were enrolled. Part A: The proportion of participants with a positive response (i.e., increase from baseline in seated systolic blood pressure of ≥ 10 mmHg) was greater with the 5 and 10 mg ampreloxetine doses than with placebo or other active ampreloxetine doses. Part B: Seated blood pressure increased 15.7 mmHg 4 h after ampreloxetine and decreased 14.2 mmHg after placebo [least squares mean difference (95% CI) 29.9 mmHg (7.6-52.3); P = 0.0112]. Part C: Symptoms of dizziness/lightheadedness improved 3.1 ± 3.0 points from baseline and standing systolic blood pressure increased 11 ± 12 mmHg. After 4 weeks of withdrawal, symptoms returned to pretreatment levels. The effect of ampreloxetine on supine blood pressure was minimal throughout treatment duration. CONCLUSION Ampreloxetine was well tolerated and improved orthostatic symptoms and seated/standing blood pressure with little change in supine blood pressure. TRIAL REGISTRATION NCT02705755 (first posted March 10, 2016).
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Affiliation(s)
- Horacio Kaufmann
- Department of Neurology, Dysautonomia Center, NYU Langone Health, New York University School of Medicine, 530 First Avenue, Suite 9Q, New York, NY, 10016, USA.
| | - Ross Vickery
- Theravance Biopharma Ireland Limited, Dublin, Ireland
| | - Whedy Wang
- Formerly of Theravance Biopharma US, Inc., South San Francisco, CA, USA
| | | | - Cyndya A Shibao
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Brett Haumann
- Formerly of Theravance Biopharma UK Limited, London, UK
| | - Italo Biaggioni
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
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Jin S, Niu Z, Jiang C, Huang W, Xia F, Jin X, Liu X, Zeng X. HeTDR: Drug repositioning based on heterogeneous networks and text mining. PATTERNS 2021; 2:100307. [PMID: 34430926 PMCID: PMC8369234 DOI: 10.1016/j.patter.2021.100307] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Revised: 05/11/2021] [Accepted: 06/14/2021] [Indexed: 12/14/2022]
Abstract
Using existing knowledge to carry out drug-disease associations prediction is a vital method for drug repositioning. However, effectively fusing the biomedical text and biological network information is one of the great challenges for most current drug repositioning methods. In this study, we propose a drug repositioning method based on heterogeneous networks and text mining (HeTDR). This model can combine drug features from multiple drug-related networks, disease features from biomedical corpora with the known drug-disease associations network to predict the correlation scores between drug and disease. Experiments demonstrate that HeTDR has excellent performance that is superior to that of state-of-the-art models. We present the top 10 novel HeTDR-predicted approved drugs for five diseases and prove our model is capable of discovering potential candidate drugs for disease indications. We developed a novel DL-based method for drug repositioning (HeTDR) HeTDR succeeds in fusing networks topology information and text mining information HeTDR obtains high accuracy, excessing most state-of-the-art models HeTDR could represent an algorithm integrating multiple sources of information
Traditional drug discovery and development are often time consuming and high risk. Drug repositioning aims to expand existing indications or discover new targets by studying the approved drug compounds, thereby reducing the time, costs, and risk of drug development. We propose a novel method in drug repositioning based on heterogeneous networks and text mining (HeTDR), which combines drugs features from multiple networks and diseases features from biomedical corpora to predict the correlation scores between drugs and diseases. This prediction model has provided a potential solution for multiple information fusion and to exhibit accurate performance leading to the discovery of new drugs for indications. This algorithm could contribute a new idea to the acceleration and development of future drug repositioning by using computational methods and provide computer-aided guidance for biologists in clinical settings.
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Affiliation(s)
- Shuting Jin
- Department of Computer Science, Xiamen University, Xiamen 361005, China.,National Institute for Data Science in Health and Medicine, Xiamen University, Xiamen 361005, China.,Shenzhen Research Institute of Xiamen University, Shenzhen 518000, China
| | | | - Changzhi Jiang
- Department of Computer Science, Xiamen University, Xiamen 361005, China
| | - Wei Huang
- Department of Computer Science, Xiamen University, Xiamen 361005, China
| | - Feng Xia
- Department of Computer Science, Xiamen University, Xiamen 361005, China
| | - Xurui Jin
- MindRank AI Ltd., Hangzhou, Zhejiang 311113, China
| | - Xiangrong Liu
- Department of Computer Science, Xiamen University, Xiamen 361005, China.,National Institute for Data Science in Health and Medicine, Xiamen University, Xiamen 361005, China
| | - Xiangxiang Zeng
- School of Information Science and Engineering, Hunan University, Changsha 410082, China
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Shibao CA, Palma JA, Celedonio JE, Martinez J, Kaufmann H, Biaggioni I. Predictors of the Pressor Response to the Norepinephrine Transporter Inhibitor, Atomoxetine, in Neurogenic Orthostatic Hypotension. Hypertension 2021; 78:525-531. [PMID: 34176285 DOI: 10.1161/hypertensionaha.119.14483] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Cyndya A Shibao
- Vanderbilt Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN (C.A.S., J.E.C., I.B.)
| | - Jose-Alberto Palma
- Dysautonomia Center, Department of Neurology, NYU Langone Medical Center, NY (J.-A.P., J.M., H.K.)
| | - Jorge E Celedonio
- Vanderbilt Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN (C.A.S., J.E.C., I.B.)
| | - Jose Martinez
- Dysautonomia Center, Department of Neurology, NYU Langone Medical Center, NY (J.-A.P., J.M., H.K.)
| | - Horacio Kaufmann
- Dysautonomia Center, Department of Neurology, NYU Langone Medical Center, NY (J.-A.P., J.M., H.K.)
| | - Italo Biaggioni
- Vanderbilt Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN (C.A.S., J.E.C., I.B.)
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Norepinephrine reuptake blockade to treat neurogenic orthostatic hypotension. Clin Auton Res 2021; 31:351-353. [PMID: 33977339 PMCID: PMC8184535 DOI: 10.1007/s10286-021-00808-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 04/20/2021] [Indexed: 11/25/2022]
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20
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Lo A, Norcliffe-Kaufmann L, Vickery R, Bourdet D, Kanodia J. Pharmacokinetics and pharmacodynamics of ampreloxetine, a novel, selective norepinephrine reuptake inhibitor, in symptomatic neurogenic orthostatic hypotension. Clin Auton Res 2021; 31:395-403. [PMID: 33782836 PMCID: PMC8184714 DOI: 10.1007/s10286-021-00800-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 03/19/2021] [Indexed: 12/23/2022]
Abstract
Purpose Ampreloxetine is a novel, selective, long-acting norepinephrine reuptake (NET) inhibitor being investigated as a once-daily oral treatment for symptomatic neurogenic orthostatic hypotension (nOH) in patients with autonomic synucleinopathies. The purpose of this study was to characterize the pharmacokinetic and pharmacodynamic profiles of ampreloxetine in this target population. Methods Patients with nOH were enrolled in a multicenter, phase II clinical trial of ampreloxetine (NCT02705755). They received escalating doses over 5 days in the clinical research unit, followed by 20 weeks of open-label treatment and then a 4-week withdrawal. As neurochemical biomarkers of NET inhibition, we assayed plasma concentrations of norepinephrine (NE) and its main intraneuronal metabolite 3,4-dihydroxyphenylglycol (DHPG) pre- and post-ampreloxetine. Results Thirty-four patients with nOH were enrolled. Plasma ampreloxetine concentrations increased with repeated escalating doses, with peak concentrations observed 6–9 h post-drug administration. The median ampreloxetine dose in the 20-week treatment phase was 10 mg once daily. Plasma ampreloxetine concentrations reached steady state by 2 weeks, with stable plasma levels over 24 h. No influence of age or renal function on ampreloxetine plasma concentrations was observed. On treatment, compared to baseline, plasma NE significantly increased by 71% (p < 0.005), plasma DHPG significantly declined by 22% (p < 0.05), and the NE:DHPG ratio significantly increased (p < 0.001). Conclusions Persistent elevation of plasma NE levels accompanied by reduced DHPG levels after ampreloxetine suggests reduced neuronal reuptake and metabolism of NE in postganglionic efferent sympathetic neurons. The findings are consistent with long-lasting NET inhibition, which may increase vasoconstrictor tone, supporting once-daily ampreloxetine dosing in patients with nOH.
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Affiliation(s)
- Arthur Lo
- Clinical and Translational Pharmacology, Theravance Biopharma US, Inc., 901 Gateway Boulevard, South San Francisco, CA, 94080, USA
| | - Lucy Norcliffe-Kaufmann
- Clinical and Translational Pharmacology, Theravance Biopharma US, Inc., 901 Gateway Boulevard, South San Francisco, CA, 94080, USA.,Clinical Science, Neurology, Theravance Biopharma US, Inc., 901 Gateway Boulevard, South San Francisco, CA, 94080, USA
| | - Ross Vickery
- Theravance Biopharma Ireland Limited, Dublin, Ireland
| | - David Bourdet
- Clinical and Translational Pharmacology, Theravance Biopharma US, Inc., 901 Gateway Boulevard, South San Francisco, CA, 94080, USA
| | - Jitendra Kanodia
- Clinical and Translational Pharmacology, Theravance Biopharma US, Inc., 901 Gateway Boulevard, South San Francisco, CA, 94080, USA.
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Isaacson SH, Dashtipour K, Mehdirad AA, Peltier AC. Management Strategies for Comorbid Supine Hypertension in Patients with Neurogenic Orthostatic Hypotension. Curr Neurol Neurosci Rep 2021; 21:18. [PMID: 33687577 PMCID: PMC7943503 DOI: 10.1007/s11910-021-01104-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/21/2021] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW In autonomic failure, neurogenic orthostatic hypotension (nOH) and neurogenic supine hypertension (nSH) are interrelated conditions characterized by postural blood pressure (BP) dysregulation. nOH results in a sustained BP drop upon standing, which can lead to symptoms that include lightheadedness, orthostatic dizziness, presyncope, and syncope. nSH is characterized by elevated BP when supine and, although often asymptomatic, may increase long-term cardiovascular and cerebrovascular risk. This article reviews the pathophysiology and clinical characteristics of nOH and nSH, and describes the management of patients with both nOH and nSH. RECENT FINDINGS Pressor medications required to treat the symptoms of nOH also increase the risk of nSH. Because nOH and nSH are hemodynamically opposed, therapies to treat one condition may exacerbate the other. The management of patients with nOH who also have nSH can be challenging and requires an individualized approach to balance the short- and long-term risks associated with these conditions. Approaches to manage neurogenic BP dysregulation include nonpharmacologic approaches and pharmacologic treatments. A stepwise treatment approach is presented to help guide neurologists in managing patients with both nOH and nSH.
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Affiliation(s)
- Stuart H Isaacson
- Parkinson's Disease and Movement Disorders Center of Boca Raton, 951 NW 13th Street, Bldg. 5-E, Boca Raton, FL, USA.
| | - Khashayar Dashtipour
- Division of Movement Disorders, Department of Neurology, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Ali A Mehdirad
- Wright State University, Dayton VA Medical Center, Dayton, OH, USA
| | - Amanda C Peltier
- Department of Neurology and Medicine, Vanderbilt University, Nashville, TN, USA
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Abstract
PURPOSE OF REVIEW This article reviews the management of orthostatic hypotension with emphasis on neurogenic orthostatic hypotension. RECENT FINDINGS Establishing whether the cause of orthostatic hypotension is a pathologic lesion in sympathetic neurons (ie, neurogenic orthostatic hypotension) or secondary to other medical causes (ie, non-neurogenic orthostatic hypotension) can be achieved by measuring blood pressure and heart rate at the bedside. Whereas fludrocortisone has been extensively used as first-line treatment in the past, it is associated with adverse events including renal and cardiac failure and increased risk of all-cause hospitalization. Distinguishing whether neurogenic orthostatic hypotension is caused by central or peripheral dysfunction has therapeutic implications. Patients with peripheral sympathetic denervation respond better to norepinephrine agonists/precursors such as droxidopa, whereas patients with central autonomic dysfunction respond better to norepinephrine reuptake inhibitors. SUMMARY Management of orthostatic hypotension is aimed at improving quality of life and reducing symptoms rather than at normalizing blood pressure. Nonpharmacologic measures are the key to success. Pharmacologic options include volume expansion with fludrocortisone and sympathetic enhancement with midodrine, droxidopa, and norepinephrine reuptake inhibitors. Neurogenic supine hypertension complicates management of orthostatic hypotension and is primarily ameliorated by avoiding the supine position and sleeping with the head of the bed elevated.
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Shibao CA, Biaggioni I. Management of Orthostatic Hypotension, Postprandial Hypotension, and Supine Hypertension. Semin Neurol 2020; 40:515-522. [PMID: 33058087 DOI: 10.1055/s-0040-1713886] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
This review provides recommendations for the treatment of neurogenic orthostatic hypotension (nOH), postprandial hypotension, and supine hypertension. It focuses on novel treatment strategies and new insights into the mechanism underlying these conditions. Our goal is to provide practical advice for clinicians on how to screen, diagnose, and treat these conditions with nonpharmacological and pharmacological approaches. For each disorder, we offered a stepwise recommendation on how to apply these new concepts to successfully ameliorate the symptoms associated with OH to prevent syncope and falls. The management of OH in patients who also have supine hypertension requires special considerations and pharmacotherapy. It is noteworthy that there are few therapeutic options for OH and only two Food and Drug Administration-approved drugs for the treatment of OH and nOH based on randomized clinical trials. We will use these studies to develop evidence-based guidelines for OH. The research is limited for postprandial hypotension and supine hypertension, and therefore the recommendations will be based on small studies, clinical expertise, and, above all, an understanding of the underlying pathophysiology.
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Affiliation(s)
- Cyndya A Shibao
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Italo Biaggioni
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
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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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Palma JA, Kaufmann H. Clinical Trials for Neurogenic Orthostatic Hypotension: A Comprehensive Review of Endpoints, Pitfalls, and Challenges. Semin Neurol 2020; 40:523-539. [PMID: 32906173 DOI: 10.1055/s-0040-1713846] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Neurogenic orthostatic hypotension (nOH) is among the most debilitating nonmotor features of patients with Parkinson's disease (PD) and other synucleinopathies. Patients with PD and nOH generate more hospitalizations, make more emergency room visits, create more telephone calls/mails to doctors, and have earlier mortality than those with PD but without nOH. Overall, the health-related cost in patients with PD and OH is 2.5-fold higher compared with patients with PD without OH. Hence, developing effective therapies for nOH should be a research priority. In the last few decades, improved understanding of the pathophysiology of nOH has led to the identification of therapeutic targets and the development and approval of two drugs, midodrine and droxidopa. More effective and safer therapies, however, are still needed, particularly agents that could selectively increase blood pressure only in the standing position because supine hypertension is the main limitation of available drugs. Here we review the design and conduct of nOH clinical trials in patients with PD and other synucleinopathies, summarize the results of the most recently completed and ongoing trials, and discuss challenges, bottlenecks, and potential remedies.
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Affiliation(s)
- Jose-Alberto Palma
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, New York, New York
| | - Horacio Kaufmann
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, New York, New York
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Park JW, Okamoto LE, Shibao CA, Biaggioni I. Pharmacologic treatment of orthostatic hypotension. Auton Neurosci 2020; 229:102721. [PMID: 32979782 DOI: 10.1016/j.autneu.2020.102721] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 08/18/2020] [Accepted: 08/23/2020] [Indexed: 12/20/2022]
Abstract
Neurogenic orthostatic hypotension (OH) is a disabling disorder caused by impairment of the normal autonomic compensatory mechanisms that maintain upright blood pressure. Nonpharmacologic treatment is always the first step in the management of this condition, but a considerable number of patients will require pharmacologic therapies. Denervation hypersensitivity and impairment of baroreflex buffering makes these patients sensitive to small doses of pressor agents. Understanding the underlying pathophysiology can help in selecting between treatment options. In general, patients with low "sympathetic reserve", i.e., those with peripheral noradrenergic degeneration (pure autonomic failure, Parkinson's disease) and low plasma norepinephrine, tend to respond better to "norepinephrine replacers" (midodrine and droxidopa). On the other hand, patients with relatively preserved "sympathetic reserve", i.e., those with impaired central autonomic pathways but spared peripheral noradrenergic fibers (multiple system atrophy) and normal or slightly reduced plasma norepinephrine, tend to respond better to "norepinephrine enhancers" (pyridostigmine, atomoxetine, and yohimbine). There is, however, a spectrum of responses within these extremes, and treatment should be individualized. Other nonspecific treatments include fludrocortisone and octreotide. The presence of associated clinical conditions, such as supine hypertension, heart failure, postprandial hypotension, PD, MSA, and diabetes need to be considered in the pharmacologic management of these patients.
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Affiliation(s)
- Jin-Woo Park
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States of America; Institute for Inflammation Control, Korea University, Seoul, Republic of Korea
| | - Luis E Okamoto
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Cyndya A Shibao
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Italo Biaggioni
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States of America; Department of Pharmacology, Vanderbilt University Medical Center, Nashville, TN, United States of America.
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Pharmacokinetics of Ampreloxetine, a Norepinephrine Reuptake Inhibitor, in Healthy Subjects and Adults with Attention-Deficit/Hyperactive Disorder or Fibromyalgia Pain. Clin Pharmacokinet 2020; 60:121-131. [PMID: 32856281 PMCID: PMC7808980 DOI: 10.1007/s40262-020-00918-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background and Objective Ampreloxetine is a novel norepinephrine reuptake inhibitor in development for the treatment of symptomatic neurogenic orthostatic hypotension. The objectives of this analysis were to define the pharmacokinetics of once-daily oral ampreloxetine and provide dose recommendations for clinical development. Methods We fitted a population pharmacokinetic model to ampreloxetine plasma concentrations from single- and multiple-ascending dose trials in healthy subjects and two phase II studies in adult subjects with attention-deficit/hyperactive disorder or fibromyalgia at doses of 2–50 mg. Results Ampreloxetine pharmacokinetics was best described by a two-compartment model with first-order absorption and elimination. The terminal half-life was 30–40 h, resulting in sustained drug concentrations for the entire 24-h dosing interval at steady state. Covariates of age, weight, or renal impairment did not impact ampreloxetine exposure. Cytochrome P450 2D6 phenotype had no influence on ampreloxetine exposure. Sex and smoking status were identified as statistically significant covariates, suggesting a role for cytochrome P450 1A2 in the elimination of ampreloxetine. Despite statistical significance, differences in ampreloxetine exposure in male vs female subjects and smokers vs non-smokers were not clinically meaningful at the recommended dose. At the 10-mg dose, > 75% norepinephrine transporter inhibition and < 50% serotonin transporter inhibition are anticipated for adult subjects. Conclusions The population pharmacokinetic model effectively described the plasma concentration–time profile of ampreloxetine after single and multiple doses. Population pharmacokinetic/pharmacodynamic analysis justified using a fixed dosing regimen with no dose adjustments across a broad population and can be used to inform dosing strategies in future clinical studies. Clinical Trial Registration ClinicalTrials.gov identifier numbers NCT01693692 (fibromyalgia); NCT01458340 (attention-deficit/hyperactive disorder). Electronic supplementary material The online version of this article (10.1007/s40262-020-00918-7) contains supplementary material, which is available to authorized users.
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Olshansky B, Muldowney J. Cardiovascular Safety Considerations in the Treatment of Neurogenic Orthostatic Hypotension. Am J Cardiol 2020; 125:1582-1593. [PMID: 32204870 DOI: 10.1016/j.amjcard.2020.01.037] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 01/18/2020] [Accepted: 01/22/2020] [Indexed: 12/17/2022]
Abstract
Neurogenic orthostatic hypotension (nOH), a drop in blood pressure upon standing resulting from autonomic malfunction, may cause debilitating symptoms that can affect independence in daily activities and quality-of-life. nOH may also be associated with cardiovascular comorbidities (e.g., supine hypertension, heart failure, diabetes, and arrhythmias), making treatment decisions complicated and requiring management that should be based on a patient's cardiovascular profile. Additionally, drugs used to treat the cardiovascular disorders (e.g., vasodilators, β-blockers) can exacerbate nOH and concomitant symptoms. When orthostatic symptoms are severe and not effectively managed with nonpharmacologic strategies (e.g., water ingestion, abdominal compression), droxidopa or midodrine may be effective. Droxidopa may be less likely than midodrine to exacerbate supine hypertension, based on conclusions of a limited meta-analysis. In conclusion, treating nOH in patients with cardiovascular conditions requires a balance between symptom relief and minimizing adverse outcomes.
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Quarracino C, Otero-Losada M, Capani F, Pérez-Lloret S. State-of-the-art pharmacotherapy for autonomic dysfunction in Parkinson’s disease. Expert Opin Pharmacother 2020; 21:445-457. [DOI: 10.1080/14656566.2020.1713097] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Cecilia Quarracino
- Institute of Cardiological Research, University of Buenos Aires, National Research Council, ININCA, UBA, CONICET, Buenos Aires, Argentina
| | - Matilde Otero-Losada
- Institute of Cardiological Research, University of Buenos Aires, National Research Council, ININCA, UBA, CONICET, Buenos Aires, Argentina
| | - Francisco Capani
- Institute of Cardiological Research, University of Buenos Aires, National Research Council, ININCA, UBA, CONICET, Buenos Aires, Argentina
| | - Santiago Pérez-Lloret
- Institute of Cardiological Research, University of Buenos Aires, National Research Council, ININCA, UBA, CONICET, Buenos Aires, Argentina
- Department of Physiology, School of Medicine, University of Buenos Aires (UBA), Buenos Aires, Argentina
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Byun JI, Kim DY, Moon J, Shin HR, Sunwoo JS, Lee WJ, Lee HS, Park KI, Lee ST, Jung KH, Jung KY, Kim M, Lee SK, Chu K. Efficacy of atomoxetine versus midodrine for neurogenic orthostatic hypotension. Ann Clin Transl Neurol 2019; 7:112-120. [PMID: 31856425 PMCID: PMC6952305 DOI: 10.1002/acn3.50968] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Revised: 11/21/2019] [Accepted: 11/22/2019] [Indexed: 11/11/2022] Open
Abstract
Objective The efficacy and safety of 1‐month atomoxetine and midodrine therapies were compared. Three‐month atomoxetine and combination therapies were investigated for additional benefits. Methods This prospective open‐label randomized trial included 50 patients with symptomatic neurogenic orthostatic hypotension (nOH). The patients received either atomoxetine 18 mg daily or midodrine 5 mg twice daily and were evaluated 1 and 3 months later. Those who still met the criteria for nOH at 1 month received both midodrine and atomoxetine for an additional 2 months, and if not, they continued their initial medication. The primary outcome was an improvement in orthostatic blood pressure (BP) drop (maximum BP change from supine to 3 min after standing) at 1 month. The secondary endpoints were symptom scores, percentage of patients with nOH at 1 and 3 months. Results Patients with midodrine or atomoxetine treatment showed comparative improvement in the orthostatic BP drop, and overall only 26.2% of the patients had nOH at 1 month, which was similar between the treatment groups. Only atomoxetine resulted in significant symptomatic improvements at 1 month. For those without nOH at 1 month, there was additional symptomatic improvement at 3 months with their initial medication. For those with nOH at 1 month, the combination treatment resulted in no additional improvement. Mild‐to‐moderate adverse events were reported by 11.6% of the patients. Interpretation One‐month atomoxetine treatment was effective and safe in nOH patients. Atomoxetine improved orthostatic BP changes as much as midodrine and was better in terms of ameliorating nOH symptoms.
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Affiliation(s)
- Jung-Ick Byun
- Laboratory for Neurotherapeutics, Department of Neurology, Comprehensive Epilepsy Center, Center for Medical Innovations, Biomedical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea.,Department of Neurology, Kyung Hee University Hospital at Gangdong, Seoul, Republic of Korea.,Program in Neuroscience, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Do-Yong Kim
- Laboratory for Neurotherapeutics, Department of Neurology, Comprehensive Epilepsy Center, Center for Medical Innovations, Biomedical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jangsup Moon
- Laboratory for Neurotherapeutics, Department of Neurology, Comprehensive Epilepsy Center, Center for Medical Innovations, Biomedical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea.,Program in Neuroscience, Seoul National University College of Medicine, Seoul, Republic of Korea.,Rare Disease Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - Hye-Rim Shin
- Laboratory for Neurotherapeutics, Department of Neurology, Comprehensive Epilepsy Center, Center for Medical Innovations, Biomedical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea.,Program in Neuroscience, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jun-Sang Sunwoo
- Laboratory for Neurotherapeutics, Department of Neurology, Comprehensive Epilepsy Center, Center for Medical Innovations, Biomedical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea.,Department of Neurosurgery, Seoul National University Hospital, Seoul, Republic of Korea
| | - Woo-Jin Lee
- Laboratory for Neurotherapeutics, Department of Neurology, Comprehensive Epilepsy Center, Center for Medical Innovations, Biomedical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea.,Program in Neuroscience, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Han-Sang Lee
- Laboratory for Neurotherapeutics, Department of Neurology, Comprehensive Epilepsy Center, Center for Medical Innovations, Biomedical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea.,Program in Neuroscience, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Kyung-Il Park
- Department of Neurology, Seoul National University Hospital Healthcare System Gangnam Center, Seoul, Republic of Korea
| | - Soon-Tae Lee
- Laboratory for Neurotherapeutics, Department of Neurology, Comprehensive Epilepsy Center, Center for Medical Innovations, Biomedical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea.,Program in Neuroscience, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Keun-Hwa Jung
- Laboratory for Neurotherapeutics, Department of Neurology, Comprehensive Epilepsy Center, Center for Medical Innovations, Biomedical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea.,Program in Neuroscience, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Ki-Young Jung
- Laboratory for Neurotherapeutics, Department of Neurology, Comprehensive Epilepsy Center, Center for Medical Innovations, Biomedical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea.,Program in Neuroscience, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Manho Kim
- Laboratory for Neurotherapeutics, Department of Neurology, Comprehensive Epilepsy Center, Center for Medical Innovations, Biomedical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea.,Program in Neuroscience, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Sang Kun Lee
- Laboratory for Neurotherapeutics, Department of Neurology, Comprehensive Epilepsy Center, Center for Medical Innovations, Biomedical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea.,Program in Neuroscience, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Kon Chu
- Laboratory for Neurotherapeutics, Department of Neurology, Comprehensive Epilepsy Center, Center for Medical Innovations, Biomedical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea.,Program in Neuroscience, Seoul National University College of Medicine, Seoul, Republic of Korea
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Okamoto LE, Shibao CA, Gamboa A, Diedrich A, Raj SR, Black BK, Robertson D, Biaggioni I. Synergistic Pressor Effect of Atomoxetine and Pyridostigmine in Patients With Neurogenic Orthostatic Hypotension. Hypertension 2019; 73:235-241. [PMID: 30571543 DOI: 10.1161/hypertensionaha.118.11790] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Patients with autonomic failure are characterized by disabling orthostatic hypotension because of impaired sympathetic activity, but even severely affected patients have residual sympathetic tone which can be harnessed for their treatment. For example, norepinephrine transporter blockade with atomoxetine raises blood pressure (BP) in autonomic failure patients by increasing synaptic norepinephrine concentrations; acetylcholinesterase inhibition with pyridostigmine increases BP by facilitating ganglionic cholinergic neurotransmission to increase sympathetic outflow. We tested the hypothesis that pyridostigmine will potentiate the pressor effect of atomoxetine and improve orthostatic tolerance and symptoms in patients with severe autonomic failure. Twelve patients received a single oral dose of either placebo, pyridostigmine 60 mg, atomoxetine 18 mg or the combination on separate days in a single blind, crossover study. BP was assessed seated and standing before and 1-hour postdrug. In these severely affected patients, neither pyridostigmine nor atomoxetine improved BP or orthostatic tolerance compared with placebo. The combination, however, significantly increased seated BP in a synergistic manner (133±9/80±4 versus 107±6/66±4 mm Hg for placebo, 105±5/67±3 mm Hg for atomoxetine, and 99±6/64±4 mm Hg for pyridostigmine; P<0.001); the maximal increase in seated BP with the combination was 33±8/18±3 mm Hg at 60 minutes postdrug. Only the combination showed a significant improvement of orthostatic tolerance and symptoms. In conclusion, the combination pyridostigmine and atomoxetine had a synergistic effect on seated BP which was associated with improvement in orthostatic tolerance and symptoms. This pharmacological approach could be useful in patients with severe autonomic failure but further safety and long-term efficacy studies are needed.
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Affiliation(s)
- Luis E Okamoto
- From the Vanderbilt Autonomic Dysfunction Center (L.E.O., C.A.S., A.G. A.D., S.R.R., B.K.B., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN.,Division of Clinical Pharmacology (L.E.O., C.A.S., A.G., A.D., S.R.R., B.K.B., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN.,Department of Medicine (L.E.O., C.A.S., A.G., A.D., S.R.R., B.K.B., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN
| | - Cyndya A Shibao
- From the Vanderbilt Autonomic Dysfunction Center (L.E.O., C.A.S., A.G. A.D., S.R.R., B.K.B., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN.,Division of Clinical Pharmacology (L.E.O., C.A.S., A.G., A.D., S.R.R., B.K.B., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN.,Department of Medicine (L.E.O., C.A.S., A.G., A.D., S.R.R., B.K.B., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN
| | - Alfredo Gamboa
- From the Vanderbilt Autonomic Dysfunction Center (L.E.O., C.A.S., A.G. A.D., S.R.R., B.K.B., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN.,Division of Clinical Pharmacology (L.E.O., C.A.S., A.G., A.D., S.R.R., B.K.B., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN.,Department of Medicine (L.E.O., C.A.S., A.G., A.D., S.R.R., B.K.B., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN
| | - André Diedrich
- From the Vanderbilt Autonomic Dysfunction Center (L.E.O., C.A.S., A.G. A.D., S.R.R., B.K.B., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN.,Division of Clinical Pharmacology (L.E.O., C.A.S., A.G., A.D., S.R.R., B.K.B., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN.,Department of Medicine (L.E.O., C.A.S., A.G., A.D., S.R.R., B.K.B., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN.,Department of Biomedical Engineering (A.D.), Vanderbilt University School of Medicine, Nashville, TN
| | - Satish R Raj
- From the Vanderbilt Autonomic Dysfunction Center (L.E.O., C.A.S., A.G. A.D., S.R.R., B.K.B., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN.,Division of Clinical Pharmacology (L.E.O., C.A.S., A.G., A.D., S.R.R., B.K.B., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN.,Department of Medicine (L.E.O., C.A.S., A.G., A.D., S.R.R., B.K.B., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN.,Department of Pharmacology (S.R.R., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN.,Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, University of Calgary, Canada (S.R.R.)
| | - Bonnie K Black
- From the Vanderbilt Autonomic Dysfunction Center (L.E.O., C.A.S., A.G. A.D., S.R.R., B.K.B., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN.,Division of Clinical Pharmacology (L.E.O., C.A.S., A.G., A.D., S.R.R., B.K.B., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN.,Department of Medicine (L.E.O., C.A.S., A.G., A.D., S.R.R., B.K.B., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN
| | - David Robertson
- From the Vanderbilt Autonomic Dysfunction Center (L.E.O., C.A.S., A.G. A.D., S.R.R., B.K.B., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN.,Division of Clinical Pharmacology (L.E.O., C.A.S., A.G., A.D., S.R.R., B.K.B., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN.,Department of Medicine (L.E.O., C.A.S., A.G., A.D., S.R.R., B.K.B., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN.,Department of Pharmacology (S.R.R., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN.,Department of Neurology (D.R.), Vanderbilt University School of Medicine, Nashville, TN
| | - Italo Biaggioni
- From the Vanderbilt Autonomic Dysfunction Center (L.E.O., C.A.S., A.G. A.D., S.R.R., B.K.B., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN.,Division of Clinical Pharmacology (L.E.O., C.A.S., A.G., A.D., S.R.R., B.K.B., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN.,Department of Medicine (L.E.O., C.A.S., A.G., A.D., S.R.R., B.K.B., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN.,Department of Pharmacology (S.R.R., D.R., I.B.), Vanderbilt University School of Medicine, Nashville, TN
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Sheldon RS, Lei L, Guzman JC, Kus T, Ayala-Paredes FA, Angihan J, Safdar S, Maxey C, Bennett G, Raj SR. A proof of principle study of atomoxetine for the prevention of vasovagal syncope: the Prevention of Syncope Trial VI. Europace 2019; 21:1733-1741. [DOI: 10.1093/europace/euz250] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 08/14/2019] [Indexed: 11/13/2022] Open
Abstract
Abstract
Aims
There are few effective therapies for vasovagal syncope (VVS). Pharmacological norepinephrine transporter (NET) inhibition increases sympathetic tone and decreases tilt-induced syncope in healthy subjects. Atomoxetine is a potent and highly selective NET inhibitor. We tested the hypothesis that atomoxetine prevents tilt-induced syncope.
Methods and results
Vasovagal syncope patients were given two doses of study drug [randomized to atomoxetine 40 mg (n = 27) or matched placebo (n = 29)] 12 h apart, followed by a 60-min drug-free head-up tilt table test. Beat-to-beat heart rate (HR), blood pressure (BP), and cardiac haemodynamics were recorded using non-invasive techniques and stroke volume modelling. Patients were 35 ± 14 years (73% female) with medians of 12 lifetime and 3 prior year faints. Fewer subjects fainted with atomoxetine than with placebo [10/29 vs. 19/27; P = 0.003; risk ratio 0.49 (confidence interval 0.28–0.86)], but equal numbers of patients developed presyncope or syncope (23/29 vs. 21/27). Of patients who developed only presyncope, 87% (13/15) had received atomoxetine. Patients with syncope had lower nadir mean arterial pressure than subjects with only presyncope (39 ± 18 vs. 69 ± 18 mmHg, P < 0.0001), and this was due to lower trough HRs in subjects with syncope (67 ± 30 vs. 103 ± 32 b.p.m., P = 0.006) and insignificantly lower cardiac index (2.20 ± 1.36 vs. 2.84 ± 1.05 L/min/m2, P = 0.075). There were no significant differences in stroke volume index (32 ± 6 vs. 35 ± 5 mL/m2, P = 0.29) or systemic vascular resistance index (2156 ± 602 vs. 1790 ± 793 dynes*s/cm5*m2, P = 0.72).
Conclusion
Norepinephrine transporter inhibition significantly decreased the risk of tilt-induced syncope in VVS subjects, mainly by blunting reflex bradycardia, thereby preventing final falls in cardiac index and BP.
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Affiliation(s)
- Robert S Sheldon
- Libin Cardiovascular Institute of Alberta, Department of Cardiac Sciences, University of Calgary, 3280 Hospital Drive NW, Calgary, Alberta, Canada
| | - Lucy Lei
- Libin Cardiovascular Institute of Alberta, Department of Cardiac Sciences, University of Calgary, 3280 Hospital Drive NW, Calgary, Alberta, Canada
| | - Juan C Guzman
- Department of Medicine, McMaster University, Hamilton, Canada
| | - Teresa Kus
- Department of Pharmacology and Physiology, Universite de Montreal, and Hopital du Sacre-Coeur, Montreal, Canada
| | | | - Jesse Angihan
- Libin Cardiovascular Institute of Alberta, Department of Cardiac Sciences, University of Calgary, 3280 Hospital Drive NW, Calgary, Alberta, Canada
| | - Shahana Safdar
- Libin Cardiovascular Institute of Alberta, Department of Cardiac Sciences, University of Calgary, 3280 Hospital Drive NW, Calgary, Alberta, Canada
| | - Connor Maxey
- Libin Cardiovascular Institute of Alberta, Department of Cardiac Sciences, University of Calgary, 3280 Hospital Drive NW, Calgary, Alberta, Canada
| | - Graham Bennett
- Libin Cardiovascular Institute of Alberta, Department of Cardiac Sciences, University of Calgary, 3280 Hospital Drive NW, Calgary, Alberta, Canada
| | - Satish R Raj
- Libin Cardiovascular Institute of Alberta, Department of Cardiac Sciences, University of Calgary, 3280 Hospital Drive NW, Calgary, Alberta, Canada
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Abstract
Orthostatic hypotension (OH) is a sustained fall in blood pressure on standing that can cause symptoms of organ hypoperfusion. OH is associated with increased morbidity and mortality and leads to a significant number of hospital admissions. OH can be caused by volume depletion, blood loss, cardiac pump failure, large varicose veins, medications, or defective activation of sympathetic nerves and reduced norepinephrine release upon standing. Neurogenic OH is a frequent and disabling problem in patients with synucleinopathies such as Parkinson disease, multiple system atrophy, and pure autonomic failure, and it is commonly associated with supine hypertension. Several therapeutic options are available.
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Ahmed A, Ruzieh M, Kanjwal S, Kanjwal K. Syndrome of Supine Hypertension with Orthostatic Hypotension: Pathophysiology and Clinical Approach. Curr Cardiol Rev 2019; 16:48-54. [PMID: 31215392 PMCID: PMC7393597 DOI: 10.2174/1573403x15666190617095032] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 05/04/2019] [Accepted: 05/07/2019] [Indexed: 12/20/2022] Open
Abstract
This article is intended to provide guidance and clinical considerations for physicians managing patients suffering from supine hypertension with orthostatic hypotension, referred to as “SH-OH”. We review the normal physiologic response to orthostasis, focusing on the appropriate changes to autonomic output in this state. Autonomic failure is discussed with a generalized overview of the disease and examination of specific syndromes that help shed light on the pathophysiology of SH-OH. The goal of this review is to provide a better framework for clinical evaluation of these patients, review treatment options, and ultimately work toward achieving a better quality of life for patients afflicted with this disease.
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Affiliation(s)
- Aamir Ahmed
- Department of Internal Medicine, Rush University, Chicago, IL 60612, United States
| | - Mohammed Ruzieh
- Penn State Heart and Vascular Institute. Hershey, PA 17033, United States
| | | | - Khalil Kanjwal
- McLaren Greater Lansing Hospital, Lansing, MI 48910, United States
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Abstract
Abstract
Attention deficit/hyperactivity disorder (ADHD) is one of the most frequently seen mental disorders in children with an increasing risk for other mental disorders. ADHD represents a primary biological dysfunction of the central nervous system, such as dysregulation of frontal-subcortical-cerebellar catecholaminergic circuits and imbalances in the dopaminergic system. However, autonomic nervous system, comprised of two primary branches - sympathetic and parasympathetic nervous systems that are normally in dynamic balance, plays an essential role in the regulation of body functions. Although it is generally assumed that the autonomic regulation is impaired during ADHD the information related to this dysregulation is limited. One of the options to observe changes of autonomic balance in ADHD is pupillary light reflex (PLR). Pupillometric evaluation can be used for the assessment of functioning of both autonomic nervous system branches and certain parameters of pupil responsivity can be helpful as a tool for medical diagnostic and treatment. In conclusion, these findings suggest the pupillometry as a non-invasive method that can indicate abnormalities in the complex central autonomic network regulating PLR.
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36
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Biaggioni I. Orthostatic Hypotension in the Hypertensive Patient. Am J Hypertens 2018; 31:1255-1259. [PMID: 29982276 DOI: 10.1093/ajh/hpy089] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Accepted: 06/27/2018] [Indexed: 12/29/2022] Open
Abstract
Orthostatic hypotension (OH) is an important and common medical problem, particularly in the frail elderly with multiple comorbidities and polypharmacy. OH is an independent risk factor for falls and overall mortality. Hypertension is among the most common comorbidities associated with OH, and its presence complicates the management of these patients because treatment of one can worsen the other. However, there is evidence that uncontrolled hypertension worsens OH so that both should be managed. The limited data available suggest that angiotensin receptor blockers and calcium channel blockers are preferable antihypertensives for these patients. Patients with isolated supine hypertension can be treated with bedtime doses of short-acting antihypertensives. Treatment of OH in the hypertensive patients should focus foremost on the removal of drugs that can worsen OH, including ones that are easily overlooked, such as tamsulosin, tizanidine, sildenafil, trazodone, and carvedilol. OH and postprandial hypotension can be prevented with abdominal binders and acarbose, respectively, without the need to increase baseline blood pressure. Upright blood pressure can be improved by harnessing residual sympathetic tone with atomoxetine, which blocks norepinephrine reuptake in nerve terminals, and pyridostigmine, which facilitates cholinergic neurotransmission in autonomic ganglia. Oral water bolus acutely but transiently increases blood pressure in autonomic failure patients. If traditional pressor agents are needed, midodrine and droxidopa can be used, administered at the lowest dose and frequency that improves symptoms. Management of OH in the hypertensive patient is challenging, but a management strategy based on understanding the underlying pathophysiology can be effective in most patients.
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Affiliation(s)
- Italo Biaggioni
- Vanderbilt Autonomic Dysfunction Center, Division of Clinical Pharmacology, and Departments of Medicine and Pharmacology, Vanderbilt University School of Medicine, Tennessee, USA
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37
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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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38
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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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39
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Patel H, Simpson A, Palevoda G, Hale GM. Evaluating the effectiveness of atomoxetine for the treatment of primary orthostatic hypotension in adults. J Clin Hypertens (Greenwich) 2018; 20:794-797. [PMID: 29569329 DOI: 10.1111/jch.13260] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Hetal Patel
- Nova Southeastern University College of Pharmacy, Palm Beach Gardens, FL, USA
| | - Ashley Simpson
- Nova Southeastern University College of Pharmacy, Palm Beach Gardens, FL, USA
| | - Gabrielle Palevoda
- Nova Southeastern University College of Pharmacy, Palm Beach Gardens, FL, USA
| | - Genevieve M Hale
- Department of Pharmacy Practice, Nova Southeastern University College of Pharmacy, Palm Beach Gardens, FL, USA
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40
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Palma JA, Kaufmann H. Treatment of autonomic dysfunction in Parkinson disease and other synucleinopathies. Mov Disord 2018; 33:372-390. [PMID: 29508455 PMCID: PMC5844369 DOI: 10.1002/mds.27344] [Citation(s) in RCA: 130] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 01/11/2018] [Accepted: 01/24/2018] [Indexed: 12/12/2022] Open
Abstract
Dysfunction of the autonomic nervous system afflicts most patients with Parkinson disease and other synucleinopathies such as dementia with Lewy bodies, multiple system atrophy, and pure autonomic failure, reducing quality of life and increasing mortality. For example, gastrointestinal dysfunction can lead to impaired drug pharmacodynamics causing a worsening in motor symptoms, and neurogenic orthostatic hypotension can cause syncope, falls, and fractures. When recognized, autonomic problems can be treated, sometimes successfully. Discontinuation of potentially causative/aggravating drugs, patient education, and nonpharmacological approaches are useful and should be tried first. Pathophysiology-based pharmacological treatments that have shown efficacy in controlled trials of patients with synucleinopathies have been approved in many countries and are key to an effective management. Here, we review the treatment of autonomic dysfunction in patients with Parkinson disease and other synucleinopathies, summarize the nonpharmacological and current pharmacological therapeutic strategies including recently approved drugs, and provide practical advice and management algorithms for clinicians, with focus on neurogenic orthostatic hypotension, supine hypertension, dysphagia, sialorrhea, gastroparesis, constipation, neurogenic overactive bladder, underactive bladder, and sexual dysfunction. © 2018 International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Jose-Alberto Palma
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, New York, New York, USA
| | - Horacio Kaufmann
- Department of Neurology, Dysautonomia Center, New York University School of Medicine, New York, New York, USA
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Abosi O, Lopes S, Schmitz S, Fiedorowicz JG. Cardiometabolic effects of psychotropic medications. Horm Mol Biol Clin Investig 2018; 36:hmbci-2017-0065. [PMID: 29320364 DOI: 10.1515/hmbci-2017-0065] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Accepted: 10/18/2017] [Indexed: 12/27/2022]
Abstract
Background Many psychiatric disorders including schizophrenia, bipolar disorder and major depression convey an excess burden of cardiovascular morbidity and mortality. The medications used to treat these conditions may further adversely affect cardiovascular risk and exacerbate health disparities for vulnerable populations. There is a clinical need to appreciate the cardiometabolic adverse effects of psychotropic medications. Methods This paper reviews the most relevant cardiometabolic effects of psychotropic medications, organized around the components of metabolic syndrome. When known, the molecular and physiological mechanisms underlying any adverse cardiometabolic effects are detailed. Results Many commonly used psychotropic medications, particularly antipsychotics, mood stabilizers and some antidepressants, have been independently associated with cardiometabolic risk factors such as insulin resistance, obesity and dyslipidemia. Stimulants, antidepressants that inhibit reuptake of norepinephrine, some antipsychotics and valproic acid derivatives may also increase blood pressure. Conclusion Understanding, assessing and subsequently managing cardiometabolic complications of psychotropic medications are important to mitigate the excess cardiovascular morbidity and mortality in the clinical populations prescribed psychotropic medications. There is considerable variability in risk between medications and individuals. Timely management of iatrogenic cardiometabolic effects is critical.
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Affiliation(s)
- Oluchi Abosi
- Department of Psychiatry, The University of Iowa, Iowa City, IA, USA
| | - Sneha Lopes
- Department of Psychiatry, The University of Iowa, Iowa City, IA, USA
| | - Samantha Schmitz
- Department of Psychiatry, The University of Iowa, Iowa City, IA, USA.,Department of Epidemiology College of Public Health, The University of Iowa, Iowa City, IA, USA
| | - Jess G Fiedorowicz
- Department of Epidemiology College of Public Health, The University of Iowa, Iowa City, IA, USA.,Department of Psychiatry, The University of Iowa, 200 Hawkins Drive, W278 GH, Iowa City, IA 52242, USA, Phone: +319-384-9267.,Department of Internal Medicine, The University of Iowa, Iowa City, IA, USA.,François M. Abboud Cardiovascular Research Center, The University of Iowa, Iowa City, IA, USA.,Iowa Neuroscience Institute, The University of Iowa, Iowa City, IA, USA.,Obesity Research and Education Initiative, The University of Iowa, Iowa City, IA, USA
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Abstract
Cardiovascular autonomic dysfunctions, including neurogenic orthostatic hypotension, supine hypertension and post-prandial hypotension, are relatively common in patients with Parkinson disease. Recent evidence suggests that early autonomic impairment such as cardiac autonomic denervation and even neurogenic orthostatic hypotension occur prior to the appearance of the typical motor deficits associated with the disease. When neurogenic orthostatic hypotension develops, patients with Parkinson disease have an increased risk of mortality, falls, and trauma-related to falls. Neurogenic orthostatic hypotension reduces quality of life and contributes to cognitive decline and physical deconditioning. The co-existence of supine hypertension complicates the treatment of neurogenic orthostatic hypotension because it involves the use of drugs with opposing effects. Furthermore, treatment of neurogenic orthostatic hypotension is challenging because of few therapeutic options; in the past 20 years, the US Food and Drug Administration approved only two drugs for the treatment of this condition. Small, open-label or randomized studies using acute doses of different pharmacologic probes suggest benefit of other drugs as well, which could be used in individual patients under close monitoring. This review describes the pathophysiology of neurogenic orthostatic hypotension and supine hypertension in Parkinson disease. We discuss the mode of action and therapeutic efficacy of different pharmacologic agents used in the treatment of patients with cardiovascular autonomic failure.
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Affiliation(s)
- Cyndya A. Shibao
- Department of Medicine, Division of Clinical Pharmacology, Vanderbilt Autonomic Dysfunction Center, Vanderbilt University Medical Center, Nashville, TN
| | - Horacio Kaufmann
- Department of Neurology, NYU Langone Medical Center, Dysautonomia Center, 530 1st Avenue, New York, NY, 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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Abstract
Pure autonomic failure (PAF) is a rare sporadic neurodegenerative autonomic disorder characterized by slowly progressive pan autonomic failure without other features of neurologic dysfunctions. The main clinical symptoms result from neurogenic orthostatic hypotension and urinary and gastrointestinal autonomic dysfunctions. Autonomic failure in PAF is caused by neuronal degeneration of pre- and postganglionic sympathetic and parasympathetic neurons in the thoracic spinal cord and paravertebral autonomic ganglia. The presence of Lewy bodies and α-synuclein deposits in these neural structures suggests that PAF is one of Lewy body synucleinopathies, examples of which include multiple system atrophy, Parkinson disease, and Lewy body disease. There is currently no specific treatment to stop progression in PAF. Management of autonomic symptoms is the mainstay of treatment and includes management of orthostatic hypotension and supine hypertension. The prognosis for survival of PAF is better than for the other synucleinopathies.
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Biaggioni I. The Pharmacology of Autonomic Failure: From Hypotension to Hypertension. Pharmacol Rev 2017; 69:53-62. [PMID: 28011746 DOI: 10.1124/pr.115.012161] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Primary neurodegenerative autonomic disorders are characterized clinically by loss of autonomic regulation of blood pressure. The clinical picture is dominated by orthostatic hypotension, but supine hypertension is also a significant problem. Autonomic failure can result from impairment of central autonomic pathways (multiple system atrophy) or neurodegeneration of peripheral postganglionic autonomic fibers (pure autonomic failure, Parkinson's disease). Pharmacologic probes such as the ganglionic blocker trimethaphan can help us in the understanding of the underlying pathophysiology and diagnosis of these disorders. Conversely, understanding the pathophysiology is crucial in the development of effective pharmacotherapy for these patients. Autonomic failure patients provide us with an unfortunate but unique research model characterized by loss of baroreflex buffering. This greatly magnifies the effect of stimuli that would not be apparent in normal subjects. An example of this is the discovery of the osmopressor reflex: ingestion of water increases blood pressure by 30-40 mm Hg in autonomic failure patients. Animal studies indicate that the trigger of this reflex is related to hypo-osmolality in the portal circulation involving transient receptor potential vanilloid 4 receptors. Studies in autonomic failure patients have also revealed that angiotensin II can be generated through noncanonical pathways independent of plasma renin activity to contribute to hypertension. Similarly, the mineralocorticoid receptor antagonist eplerenone produces acute hypotensive effects, highlighting the presence of non-nuclear mineralocorticoid receptor pathways. These are examples of careful clinical research that integrates pathophysiology and pharmacology to advance our knowledge of human disease.
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Affiliation(s)
- Italo Biaggioni
- Division of Clinical Pharmacology, Departments of Medicine and Pharmacology, Vanderbilt University, Nashville, Tennessee
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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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Dihydroxyphenylglycol as a Biomarker of Norepinephrine Transporter Inhibition by Atomoxetine: Human Model to Assess Central and Peripheral Effects of Dosing. J Clin Psychopharmacol 2016; 36:675-683. [PMID: 27755221 DOI: 10.1097/jcp.0000000000000611] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
To assess the primary metabolite of norepinephrine, 3,4-dihydroxyphenylglycol (DHPG), as a sensitive biomarker for norepinephrine transporter (NET) function and the relationship of DHPG measured peripherally and centrally, NET was antagonized with 80 mg/d atomoxetine for 18 days. Twelve healthy subjects were treated with atomoxetine in an open-label, multiple-dose exploratory study. Plasma atomoxetine reached steady state by day 6, and the pharmacokinetic results demonstrated availability of atomoxetine to the central nervous system. The cerebrospinal fluid (CSF)/plasma ratios of atomoxetine based on area under concentration-time curve from 0 to 12 hours postdose (AUC0-12), maximum concentration (Cmax), and predose were 0.3%, 0.2%, and 11%, respectively. Plasma from atomoxetine-treated subjects (ex vivo) significantly inhibited radioligand binding to human NET (P < 0.001) only 1 hour after dosing. Plasma DHPG and DHPG/norepinephrine (ratio) during repeated posture tests were reduced significantly (P < 0.001) on day 5 and stayed significantly reduced up to 1 day after treatment. In CSF, both DHPG and the ratio were significantly reduced (P < 0.001) on day 18. Urine results showed significant decreases for both DHPG and the ratio (P = 0.010 to P < 0.001). Brain-derived neurotrophic factor in CSF was lesser than the limits of detection. The findings suggest that NET blockade can be assessed with DHPG concentration or with the ratio in plasma, CSF, and urine. The data suggest that DHPG is a useful biomarker to proactively assess the pharmacological activity of compounds intended to inhibit NET activity within the brain. The study shows that CSF is a medium for early identification and quantification of biomarkers useful in assessing novel neuroscience targets.
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Yalcin O, Aslan AA, Sari BA, Turkbay T. Possible Methylphenidate Related Hoarseness and Disturbances of Voice Quality: Two Pediatric Cases. ACTA ACUST UNITED AC 2016. [DOI: 10.5455/bcp.20120731061626] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Ozhan Yalcin
- Child and Children's Psychiatry Service, Şanlıurfa Children Hospital, Şanlıurfa - Turkey
| | | | - Burcu Akin Sari
- Department of Psychiatry, Child and Adolescent Psychiatry Unite, Başkent University School of Medicine, Ankara - Turkey
| | - Tumer Turkbay
- Department of Child and Adolescent Psychiatry, Gülhane Military Medical Academy, Ankara - Turkey
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Kilincaslan A, Mutluer TD, Pasabeyoglu B, Tutkunkardas MD, Mukaddes NM. Effects of Atomoxetine in Individuals with Attention-Deficit/Hyperactivity Disorder and Low-Functioning Autism Spectrum Disorder. J Child Adolesc Psychopharmacol 2016; 26:798-806. [PMID: 27228116 DOI: 10.1089/cap.2015.0179] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES This naturalistic, retrospective study investigated the effects of atomoxetine (ATX) on attention-deficit/hyperactivity disorder (ADHD) symptoms and autistic features in children with autism spectrum disorders (ASDs) and intellectual disability (ID). METHODS Participants (n = 37, age range 6-17 years, mean: 10.16 ± 3.60) were assessed at baseline, 4th and 12th weeks using Clinical Global Impressions (CGI) scales, DSM-IV-based ADHD-rating scale (ADHD-RS), and amended Turkish version of Aberrant Behavior Checklist (ABC). The primary outcome measure was a treatment response defined by a CGI-improvement score of 1 or 2 together with a decrease of at least 25% in the parent-rated ADHD-RS total score at the end of 12th week. RESULTS Five patients (13.5%) stopped medication at 4 weeks due to ineffectivity (2) and intolerable side effects (increased motor activity and talkativeness [n = 1], irritability [n = 2], temper outbursts [n = 2], and increased blood pressure [n = 1]). Sixteen patients (43.2%) were judged to be responders according to primary outcome measure. Improvement rate on CGI scale was 48.8%. On ADHD-RS, there were significant reductions between baseline and 4th week and between baseline and 12th week in both hyperactivity and inattention, and between baseline and 12th week in impulsivity scores. Decrease was significant in hyperactivity and social withdrawal subscales of the parent-reported ABC. Responders based on primary outcome measure were not significantly different from nonresponders in terms of sociodemographic features or clinical parameters, including intellectual, language, autism symptom, and ADHD symptom levels. CONCLUSION In this chart review, ATX appears to be safe and effective for social withdrawal and ADHD symptoms in children with ASD and ID.
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Affiliation(s)
- Ayse Kilincaslan
- Department of Child and Adolescent Psychiatry, Istanbul Faculty of Medicine, Istanbul University , Fatih, Istanbul
| | - Tuba Duzman Mutluer
- Department of Child and Adolescent Psychiatry, Istanbul Faculty of Medicine, Istanbul University , Fatih, Istanbul
| | - Basak Pasabeyoglu
- Department of Child and Adolescent Psychiatry, Istanbul Faculty of Medicine, Istanbul University , Fatih, Istanbul
| | - Mustafa Deniz Tutkunkardas
- Department of Child and Adolescent Psychiatry, Istanbul Faculty of Medicine, Istanbul University , Fatih, Istanbul
| | - Nahit Motavalli Mukaddes
- Department of Child and Adolescent Psychiatry, Istanbul Faculty of Medicine, Istanbul University , Fatih, Istanbul
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50
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McDonell KE, Shibao CA, Claassen DO. Clinical Relevance of Orthostatic Hypotension in Neurodegenerative Disease. Curr Neurol Neurosci Rep 2016; 15:78. [PMID: 26486792 DOI: 10.1007/s11910-015-0599-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
The autonomic nervous system appears to be uniquely susceptible to degeneration in disorders of α-synuclein pathology. Clinically, autonomic dysfunction in these disorders manifests as neurogenic orthostatic hypotension (nOH), a condition that results in substantial morbidity and mortality. nOH results from pathology affecting either the central autonomic pathways or peripheral autonomic nerve fibers. Determining the localization and pathophysiology of nOH is critical in effectively managing this disorder and selecting appropriate treatment options. In this review, we discuss the pathophysiology of nOH with respect to the various α-synuclein-related neurodegenerative conditions. We highlight the associated clinical features, including gait instability, rapid eye movement behavior disorder, and hyposmia. We also review the current pharmacologic treatment options for nOH. Overall, the goals of therapy are to improve symptoms and prevent syncope and falls. Non-pharmacologic interventions should be introduced first, followed by carefully selected pharmacologic therapies. Treatment decisions should be directed by an understanding of the underlying pathophysiology, as well as the comorbidities and potential contributing factors present in each individual patient.
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Affiliation(s)
- Katherine E McDonell
- Department of Neurology, Vanderbilt University Medical Center, 1161 21st Avenue South A-0118, Nashville, TN, 37232-2551, USA.
| | - Cyndya A Shibao
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Daniel O Claassen
- Department of Neurology, Vanderbilt University Medical Center, 1161 21st Avenue South A-0118, Nashville, TN, 37232-2551, USA
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