What are the treatments for dysautonomia?

From the Guidelines

Dysautonomia treatments primarily involve managing symptoms, particularly orthostatic hypotension, through a combination of non-pharmacological and pharmacological measures.

Non-Pharmacological Measures

• Identifying and avoiding other causes of orthostatic hypotension, such as volume depletion, and drugs that exacerbate postural symptoms (e.g., psychotropic drugs, diuretics, α-adrenoreceptor antagonists) 1
• Educating patients on behavioral strategies:
  • Gradual staged movements with postural change
  • Mild isotonic exercise
  • Head-up bed position during sleep
  • Physical counter-manoeuvres (e.g., leg-crossing, stooping, squatting, tensing muscles)
  • Use of portable folding chairs
  • Increased fluid and salt intake (if not contraindicated)
  • Drinking water rapidly
  • Avoidance of large meals rich in carbohydrates
• Using elastic garments over the legs and abdomen 1

Pharmacological Treatments

• Midodrine: A first-line drug, peripheral selective α1-adrenergic agonist, which exerts a pressor effect through arteriolar constriction and venoconstriction of capacitance vessels. Dosing should be individually tailored (up to two to four times 10 mg/day) 1
• 9-α-fluorohydrocortisone: Another first-choice drug that acts through sodium retention, direct constricting effect on partially denervated vessels, and increase in water content of the vessel wall. Initial dose should be 0.05–0.1 mg daily with individual titration to 0.1–0.3 mg daily 1
• Erythropoietin: Proposed to increase standing blood pressure via several mechanisms, including increasing red cell mass and central blood volume, correcting anaemia, and neurohumoral effects on vascular tone regulation. Administered in diabetic patients with haemoglobin levels under 11 g/dL at doses between 25–75 U/kg three times/week 1
• Other possible treatments include desmopressin acetate, somatostatin analogues, caffeine, and acarbose, which are useful in specific contexts such as correcting nocturnal polyuria, morning orthostatic hypotension, or attenuating postprandial hypotension 1

In the context of diabetes, dysautonomia, particularly cardiac autonomic neuropathy (CAN), poses significant risks including myocardial infarction, increased cardiovascular events, and mortality 1. Management involves detecting CAN at the infra-clinical stage through standardized tests for deep respiration, active orthostatism, and the Valsalva maneuver, and avoiding drugs that may induce orthostatic hypotension 1.

From the Research

Treatment Approaches for Dysautonomia

The treatment of dysautonomia often involves a multimodal approach, including environmental modifications and pharmacotherapy 2. The goal of treatment is to manage symptoms, prevent comorbidities, and improve patient outcomes.

Pharmacological Management

Various medications can be used to manage dysautonomia, including:

• Morphine and midazolam to reduce heart rate and respiratory rate 3
• Chlorpromazine to modify respiratory rate responses 3
• Propanolol, bromocriptine, and intrathecal baclofen to manage symptoms 3
• Fludrocortisone, midodrine, and droxidopa to treat neurogenic orthostatic hypotension (nOH) 4
• Losartan, captopril, clonidine, and nitrate patches to manage supine hypertension 4

Non-Pharmacological Interventions

Non-pharmacological interventions can also be effective in managing dysautonomia, including:

• Postural care and good hydration 4
• Higher salt intake and use of compression stockings and abdominal straps 4
• Portioned meals and supervised physical activity, mainly sitting, lying down, or exercising in water 4
• Sleeping with the head elevated (20-30 cm) and avoiding getting up at night 4

Treatment of Specific Conditions

Different conditions related to dysautonomia may require specific treatments, such as:

• Chronic fatigue syndrome: midodrine treatment has been shown to correct dysautonomia and improve fatigue 5
• Postural orthostatic tachycardia syndrome (POTS): treatment focuses on managing symptoms and improving quality of life 4
• Neurogenic orthostatic hypotension (nOH): treatment aims to manage symptoms and prevent supine hypertension 4