eMedicine Specialties > Neurology > Neuro-oncology

Paraneoplastic Autonomic Neuropathy: Treatment & Medication

Author: Bjorn E Oskarsson, MD, Assistant Professor, Department of Neurology, University of California Davis
Coauthor(s): Dianna Quan, MD, Associate Professor of Neurology, Director, Electromyography Laboratory, University of Colorado Health Sciences Center; Ronald G Wiley, MD, PhD, Chief, Professor, Department of Neurology, Veterans Affairs Medical Center, Vanderbilt University
Contributor Information and Disclosures

Updated: Jul 12, 2006

Treatment

Medical Care

Care of patients with paraneoplastic autonomic neuropathy depends on severity of autonomic failure and status of associated malignancy.

  • Malignancy
    • The most important aspect of medical care in a patient with paraneoplastic autonomic dysfunction is treatment of the underlying malignancy. If the malignancy can be cured, progression of autonomic dysfunction may cease and potentially even reverse. If a cure is not possible and chemotherapy is a consideration, then a nonneurotoxic regimen such as cyclophosphamide and doxorubicin (Adriamycin) that is immunosuppressive is theoretically appealing. However, no data show superiority of any particular regimen, as long as the tumor is controlled.
    • In exceptional cases, patients presenting with typical encephalomyeloneuropathy, including autonomic failure and positive antineuronal antibody titers, may be considered for chemotherapy even in the absence of a tissue diagnosis. The risk of an occult malignancy in this specific situation is very high.
  • Autoimmune process: In general, immunosuppressive treatments directed against the paraneoplastic antibodies (eg, plasmapheresis) have been disappointing, but occasional patients have had benefits23 . No therapy directed at suppressing the immune system has been shown to be reliably effective; however, successful treatment of the associated malignancy by resection and/or chemotherapy may slow or stop the progression of the neurological syndrome.
  • Autonomic failure
    • Nonpharmacologic measures are useful for all patients with autonomic dysfunction:
      • Discontinue antihypertensive medications and other medications known to lower blood pressure, if feasible.
      • Increase fluid and salt intake.
      • Equipment aids may be helpful; these include tight support stockings, abdominal binders or antigravity suits for symptomatic hypotension, and bladder catheterization for urinary retention.
      • Dietary fiber and enemas may help improve bowel motility and decrease straining during defecation.
      • Patients with decreased sweating should limit their physical activity, particularly in hot weather. Sponging with water during activity may help prevent overheating.
      • Large meals may exacerbate hypotension and should be avoided.
      • Positional changes, such as standing, should be performed slowly and gradually.
      • Elevate the head of the bed and avoid prolonged recumbency.
    • Many pharmacological interventions directed against symptoms of autonomic failure are helpful; please see the article on Idiopathic Orthostatic Hypotension and Other Autonomic Failure Syndromes for a discussion.

Consultations

If no known underlying cancer is present, consider seeking consultation from a pulmonary medicine specialist. A pulmonologist can help in finding small cell lung cancer or other lung tumor through imaging and bronchoscopy. A medical oncology specialist can be of diagnostic help, in addition to assisting in the treatment of the associated malignancy.

Gastroenterology and urology consultation may be needed if intestinal dysmotility and urinary incontinence are part of the clinical manifestations.

Diet

High fluid and salt intake is of potential value for orthostatic hypotension. A fiber rich diet can help some gastric dysmotility symptoms.

Medication

No specific drug treatment is of proven value; however, cytotoxic chemotherapy for the associated malignancy is rational. For symptomatic management of autonomic failure, see article on Idiopathic Orthostatic Hypotension and Other Autonomic Failure Syndromes for details.

More on Paraneoplastic Autonomic Neuropathy

Overview: Paraneoplastic Autonomic Neuropathy
Differential Diagnoses & Workup: Paraneoplastic Autonomic Neuropathy
Treatment & Medication: Paraneoplastic Autonomic Neuropathy
Follow-up: Paraneoplastic Autonomic Neuropathy
Multimedia: Paraneoplastic Autonomic Neuropathy
References
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References

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Further Reading

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Keywords

anti-HU disease paraneoplastic encephalomyeloneuropathy, autonomic dysfunction, paraneoplastic neurological degeneration, paraneoplastic autonomic neuropathy, PNS, paraneoplastic syndromes, autonomic neuropathy, paraneoplastic peripheral neuropathies, paraneoplastic encephalomyeloneuropathies, Lambert-Eaton myasthenic syndrome, LEMS

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Contributor Information and Disclosures

Author

Bjorn E Oskarsson, MD, Assistant Professor, Department of Neurology, University of California Davis
Bjorn E Oskarsson, MD is a member of the following medical societies: American Academy of Neurology and American Association of Neuromuscular and Electrodiagnostic Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Dianna Quan, MD, Associate Professor of Neurology, Director, Electromyography Laboratory, University of Colorado Health Sciences Center
Dianna Quan, MD is a member of the following medical societies: American Academy of Neurology, American Association of Neuromuscular and Electrodiagnostic Medicine, and Phi Beta Kappa
Disclosure: e-medicine Honoraria Other

Ronald G Wiley, MD, PhD, Chief, Professor, Department of Neurology, Veterans Affairs Medical Center, Vanderbilt University
Ronald G Wiley, MD, PhD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Neurology, American Association for the Advancement of Science, New York Academy of Sciences, and Society for Neuroscience
Disclosure: Nothing to disclose.

Medical Editor

Amy A Pruitt, MD, Associate Professor of Neurology, University of Pennsylvania; Attending Neurologist, Hospital of the University of Pennsylvania
Amy A Pruitt, MD is a member of the following medical societies: American Academy of Neurology
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Jorge Kattah, MD, Head, Program Director, Professor, Department of Neurology, University of Illinois College of Medicine at Peoria
Jorge Kattah, MD is a member of the following medical societies: American Academy of Neurology, American Neurological Association, and New York Academy of Sciences
Disclosure: Biogen Honoraria Consulting; Bayer Corporation Honoraria Consulting

CME Editor

Selim R Benbadis, MD, Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, University of South Florida School of Medicine, Tampa General Hospital
Selim R Benbadis, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Sleep Medicine, American Clinical Neurophysiology Society, American Epilepsy Society, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Tarakad S Ramachandran, MBBS, FRCP(C), FACP, Professor of Neurology, Clinical Professor of Medicine, Clinical Professor of Family Medicine, Clinical Professor of Neurosurgery, State University of New York Upstate Medical University; Chair, Department of Neurology, Crouse Irving Memorial Hospital
Tarakad S Ramachandran, MBBS, FRCP(C), FACP is a member of the following medical societies: American Academy of Neurology, American Academy of Pain Medicine, American College of Forensic Examiners, American College of International Physicians, American College of Managed Care Medicine, American College of Physicians, American Heart Association, American Stroke Association, Royal College of Physicians, Royal College of Physicians and Surgeons of Canada, Royal College of Surgeons of England, and Royal Society of Medicine
Disclosure: Abbott Labs  Honoraria Consulting; Teva Marion Honoraria Consulting; Boeringer-Ingelheim Honoraria Speaking and teaching

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