Is treatment of dysautonomia (autonomic nervous system dysfunction) effective?

From the Guidelines

Treatment for dysautonomia can be effective, and the most effective approach typically combines lifestyle modifications and medications, with midodrine and fludrocortisone being key pharmacological treatments. The goal of treatment is to improve symptoms, reduce morbidity, and enhance quality of life. According to the most recent and highest quality study 1, the first therapeutic approach in symptomatic orthostatic hypotension should consider the exclusion of drugs exacerbating orthostatic hypotension, correction of volume depletion, and other non-pharmacological measures.

Some key lifestyle modifications include:

• Increasing salt intake to increase blood volume
• Maintaining hydration to prevent dehydration
• Wearing compression garments to reduce blood pooling in the legs
• Performing recumbent exercises to improve circulation
• Using techniques like counter-maneuvers when standing to reduce symptoms of orthostatic hypotension

Pharmacological treatments may include:

• Midodrine (ProAmatine) at 2.5-10 mg three times daily to raise blood pressure
• Fludrocortisone (Florinef) at 0.1-0.2 mg daily to increase blood volume
• Beta-blockers like propranolol to manage tachycardia, although their use is not recommended in all cases of dysautonomia, as they may worsen symptoms in certain individuals 1

It's essential to note that treatment success depends on identifying the underlying cause of dysautonomia when possible, consistent adherence to the treatment plan, and regular follow-up with healthcare providers to adjust therapies as needed. While complete resolution may not always be possible, many patients experience significant improvement in their quality of life with appropriate management. As stated in 1, referral to medical centers specializing in the evaluation and treatment of autonomic failure should be considered if non-pharmacological methods and initial drug treatments are unsuccessful.

From the FDA Drug Label

Midodrine has been studied in 3 principal controlled trials, one of 3-weeks duration and 2 of 1 to 2 days duration. All studies were randomized, double-blind and parallel-design trials in patients with orthostatic hypotension of any etiology and supine-to-standing fall of systolic blood pressure of at least 15 mmHg accompanied by at least moderate dizziness/lightheadedness Midodrine-treated patients had significantly higher (by about 20 mmHg) 1-minute standing systolic pressure 1 hour after dosing Midodrine has no clinically significant effect on standing or supine pulse rates in patients with autonomic failure.

The treatment of dysautonomia (autonomic nervous system dysfunction) with midodrine is effective in increasing blood pressure in patients with orthostatic hypotension, but it does not have a clinically significant effect on heart rate.

• Key benefits: Midodrine increases standing systolic blood pressure by approximately 15 to 30 mmHg.
• Limitations: Midodrine has no significant effect on pulse rates in patients with autonomic failure. 2

From the Research

Treatment Effectiveness

The effectiveness of treatment for dysautonomia, a condition characterized by autonomic nervous system dysfunction, varies depending on the specific type and severity of the condition.

• Treatment for orthostatic hypotension, a common symptom of dysautonomia, can be effective in some cases, with medications such as fludrocortisone, midodrine, and droxidopa showing promise 3, 4, 5.
• A study on the use of oral vasopressors in the management of autonomic dysfunction and orthostatic hypotension found that a combination of intravenous vasopressors and hydration, pressure support garments, oral mineralocorticoids, and oral vasopressors can be effective in managing orthostatic hypotension 6.
• Mindfulness intervention programs have also been explored as a potential treatment for dysautonomia symptoms in patients with Long COVID, with some studies suggesting improvements in sleep quality and reductions in inflammatory gene expression 7.

Treatment Approaches

Different treatment approaches may be effective for different types of dysautonomia, including:

• Pharmacological interventions, such as the use of alpha-adrenergic agonists like midodrine, which can be effective in treating orthostatic hypotension in patients with preserved autonomic reflexes 5.
• Non-pharmacological interventions, such as postural care, good hydration, higher salt intake, and supervised physical activity, which can be important treatment steps for patients with dysautonomia 3.
• Multidisciplinary evaluation and treatment, which may be necessary for patients with moderate to advanced stages of dysautonomia, as treatment can be complex and often refractory 3.

Limitations and Challenges

Despite the availability of various treatment options, there are still significant limitations and challenges in the treatment of dysautonomia, including:

• The lack of a cure for most types of dysautonomia, particularly in late stages 3.
• The risk of exacerbating supine hypertension, which can be a major therapeutic challenge in patients with neurogenic orthostatic hypotension 3.
• The need for further research to develop more effective symptomatic and pathogenesis-targeted therapies for dysautonomia, particularly in patients with Long COVID-associated dysautonomia symptoms 7.