Idiopathic Orthostatic Hypotension and other Autonomic Failure Syndromes Medication

Several medications are available to help manage symptoms of autonomic dysfunction. The most commonly used are listed below.

Class Summary

These agents play a role in hemodynamics and can be used to control orthostatic hypotension.

Fludrocortisone (Florinef)

Used to increase standing blood pressure. Acts to increase sodium retention and expand plasma volume.

Class Summary

These agents improve the hemodynamic status by increasing myocardial contractility and heart rate, resulting in increased cardiac output. They also increase peripheral resistance by causing vasoconstriction. Increased cardiac output and increased peripheral resistance lead to increased blood pressure.

Midodrine (ProAmatine)

Alpha-adrenergic agonist used in orthostatic hypotension to increase standing blood pressure. Acts at level of resistance vessels and is useful for peripherally mediated hypotension.

Class Summary

These agents limit heart rate and reduce blood pressure.

Propranolol (Inderal)

Nonselective beta-blocker that is lipophilic (penetrates CNS).

Class Summary

These agents augment both coronary and cerebral blood flow that occurs during the low flow state associated idiopathic hypotension.

Desmopressin (DDAVP, Stimate)

Increases cellular permeability of collecting ducts, resulting in reabsorption of water by kidneys. Helpful for symptoms of nocturia.

Class Summary

Anemia may occur due to low blood levels of endogenous erythropoietin, which can result from a lack of sympathetic innervation. Erythropoietins may also increase blood pressure through other mechanisms.

Epoetin alfa (Epogen, Procrit)

Stimulates RBC production in bone marrow. Increases sensitivity to pressor effects of angiotensin II, intravascular volume, cytosolic free calcium in vascular smooth muscle, and plasma endothelin level. Enhances renal tubular reabsorption.

Class Summary

These agents promote motility of the GI tract.

Metoclopramide (Reglan)

Dopamine agonist helpful in relieving GI paresis.

Class Summary

These agents inhibit acetylcholinesterase (AChE), raising the concentration of ACh at cholinergic synapses and increasing the chance of activating the AChR.

Pyridostigmine bromide (Mestinon)

Stimulates muscarinic AChR, increasing salivation and gastric motility.

Class Summary

Used for the chronic treatment of constipation.

Psyllium (Metamucil, Fiberall)

Must be taken with water or may cause obstruction. Increase dose gradually. Inform patient that effect not immediate.

Class Summary

These agents may be helpful for urinary symptoms.

Oxybutynin (Ditropan)

Useful for urinary urgency. Inhibits action of ACh on smooth muscle and direct antispasmodic effect on smooth muscle, which increases bladder capacity and decreases uninhibited contractions.

Class Summary

These agents stimulate cholinergic receptors in the smooth muscle of the urinary bladder for stimulation of bladder emptying.

Bethanechol hydrochloride (Duvoid, Urecholine)

For selective stimulation of the bladder to produce contraction to initiate micturition and empty bladder. Most useful in bladder hypotonia. Rarely used because of GI stimulation and difficulty in timing effect.

Class Summary

These oral agents act peripherally to induce smooth muscle relaxation of the corpora cavernosa.

Sildenafil (Viagra)

Selective PDE5 inhibitor that inactivates cGMP, attenuating vasodilatory effect of NO. Effective in mild-to-moderate erectile dysfunction. Patient should take on an empty stomach about 1 h before sexual activity. Sexual stimulation necessary to activate response. Increased sensitivity for erections may last 24 h.

Class Summary

These agents regulate key factors in the immune system.

Prednisone (Deltasone, Orasone, Meticorten)

Shorten duration of symptoms and improves overall prognosis in acute pandysautonomia.

Class Summary

These agents are used to improve clinical and immunologic aspects of the disease. May decrease autoantibody production, and increase solubilization and removal of immune complexes.

Immune globulins intravenous (IVIG, Gammagard, Gamimune)

Shortens duration of symptoms and improves overall prognosis in acute pandysautonomia. Clinical improvements have been reported within few days of administration, with normalization of autonomic parameters.

Neutralize circulating myelin antibodies through antiidiotypic antibodies; down-regulates proinflammatory cytokines, including INF-gamma; blocks Fc receptors on macrophages; suppresses inducer T and B cells and augments suppressor T cells; blocks complement cascade; promotes remyelination; may increase CSF IgG (10%).