From the Guidelines
Autonomic dysfunction requires a comprehensive treatment approach, addressing the underlying condition and symptoms, with a focus on improving morbidity, mortality, and quality of life. The management of autonomic dysfunction depends on the specific symptoms and underlying cause, and may involve a combination of pharmacological and non-pharmacological interventions.
Symptoms and Treatment
- For orthostatic hypotension, increasing salt and fluid intake, wearing compression stockings, and medications like midodrine (2.5-10mg three times daily) or fludrocortisone (0.1-0.3mg daily) may be effective 1.
- Gastrointestinal symptoms, such as gastroparesis, may be managed with metoclopramide (5-10mg before meals), while loperamide (2-4mg as needed) may control diarrhea 1.
- Urinary symptoms, such as retention or incontinence, may require bethanechol (10-50mg three to four times daily) or oxybutynin (5mg twice daily) 1.
Underlying Conditions
- Diabetes control is crucial for managing diabetic autonomic neuropathy, and may involve lifestyle modifications, such as diet and exercise, as well as pharmacological interventions 1.
- Other underlying conditions, such as hypertrophic cardiomyopathy, may require specific treatments, such as medical and surgical therapy, to modify the abnormal blood pressure response to exercise 1.
Monitoring and Adjustment
- Close monitoring of pulse and blood pressure is recommended, particularly in patients with botulism or Guillain-Barré syndrome, due to the risk of autonomic dysfunction 1.
- Treatment regimens may need to be adjusted over time, as symptoms often fluctuate, and the autonomic nervous system's complex integration of sympathetic and parasympathetic pathways can affect multiple body systems simultaneously 1.
From the Research
Autonomic Dysfunction
- Autonomic dysfunction is a prevalent and debilitating condition that can significantly reduce the quality of life in patients with Parkinson's disease and other synucleinopathies 2.
- Non-pharmacological therapies are key to effective management and can be used alone or in combination with pharmacological therapies to manage autonomic symptoms 2.
- Evidence supports the effectiveness of non-pharmacological treatment for managing neurogenic orthostatic hypotension, supine hypertension, constipation, and bladder and sexual dysfunction 2.
Orthostatic Hypotension
- Orthostatic hypotension is an excessive fall in blood pressure while standing, resulting from a decrease in cardiac output or defective vasoconstrictor mechanisms 3.
- Midodrine is a prodrug that can increase standing systolic blood pressure and improve standing time and energy level in patients with orthostatic hypotension 4.
- Fludrocortisone is a mineralocorticoid that can increase blood volume and blood pressure, and is considered a first- or second-line pharmacological therapy for orthostatic hypotension 3.
- Non-pharmacological strategies, such as discontinuing offending medications, increasing fluid and salt intake, and using venous compression methods, are the primary treatment for orthostatic hypotension 5.
Treatment Options
- Midodrine is effective in treating orthostatic hypotension in patients with significant preservation of autonomic reflexes, but may exacerbate orthostatic hypotension in patients with markedly impaired baroreceptor mechanisms 6.
- Fludrocortisone may be beneficial in reducing blood pressure drop and improving orthostatic symptoms in patients with diabetes and Parkinson's disease, but the evidence is very uncertain 3.
- Pyridostigmine and droxidopa are alternative treatment options for orthostatic hypotension, and may be effective in patients who fail to respond to midodrine or fludrocortisone 5.