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Treatment options for autonomic neuropathies

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Opinion statement

Autonomic disorders may present in a varied fashion. Symptoms that may require treatment include orthostatic intolerance, gastrointestinal distress, sudomotor abnormalities, and urologic and sexual dysfunction. Realistic treatment goals should be outlined for patients, with the expectations that symptoms can be improved, but that the disease is unlikely to be cured and long-term therapy may be required. Orthostatic intolerance is usually treated by a combination of pharmacologic and nonpharmacologic therapies. Nonpharmacologic therapies include compression stockings, adequate fluid and salt intake, and lifestyle modifications. Polypharmacologic therapy is often the standard and can include a volume-expanding agent (such as fludrocortisone) and a sympathomimetic agent. This combination will improve symptoms dramatically in most patients. Treatment of gastrointestinal disorders should address the particular symptom involved: gastroparesis, constipation, or diarrhea. Treatment of sexual and urogenital dysfunction often requires a combination of pharmacologic intervention and lifestyle modifications for peak effectiveness. Patient education is the cornerstone of treatment in any of the autonomic disorders. Given enough education and motivation, many patients will be able to participate in their treatment, which will provide a feeling of empowerment and control over a disease that is often frustratingly resistant to treatment.

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References and Recommended Reading

  1. Omboni S, Smit AA, van Lieshout JJ, et al.: Mechanisms underlying the impairment in orthostatic tolerance after nocturnal recumbency in patients with autonomic failure. Clin Sci (Lond) 2001, 101:609–618.

    Article  CAS  Google Scholar 

  2. Freeman R: Treatment of orthostatic hypotension. Semin Neurol 2003, 23:435–442. A review of the treatment of OH.

    Article  PubMed  Google Scholar 

  3. Shannon J, Diedrich R, Biaggioni A, et al.: Water drinking as a treatment for orthostatic syndromes. Am J Med 2002, 112:355–360.

    Article  PubMed  Google Scholar 

  4. Schroeder C, Bush VE, Norcliffe LJ, et al.: Water drinking acutely improves orthostatic tolerance in healthy subjects. Circulation 2002, 106:2806–2811.

    Article  PubMed  Google Scholar 

  5. Freitas J, Santos R, Azevedo E, et al.: Clinical improvement in patients with orthostatic intolerance after treatment with bisoprolol and fludrocortisone. Clin Auton Res 2000, 10:293–299.

    Article  PubMed  CAS  Google Scholar 

  6. van Lieshout JJ, ten Harkel AD, Wieling W: Fludrocortisone and sleeping in the head-up position limit the postural decrease in cardiac output in autonomic failure. Clin Auton Res 2000, 10:35–42. A paper documenting nonpharmacologic therapies for treatment of orthostatic intolerance.

    Article  PubMed  Google Scholar 

  7. Kaufmann H, Brannan T, Krakoff L, et al.: Treatment of orthostatic hypotension due to autonomic failure with a peripheral alpha-adrenergic agonist (Midodrine). Neurology 1988, 38:951–956.

    PubMed  CAS  Google Scholar 

  8. Low PA, Gilden JL, Freeman R, et al.: Efficacy of Midodrine vs placebo in neurogenic orthostatic hypotension. A randomized, doubleblind multicenter study. Midodrine Study Group. JAMA 1997, 277:1046–1051. Class I evidence for use of midodrine as treatment for OH.

    Article  PubMed  CAS  Google Scholar 

  9. Wright RA, Kaufmann HC, Perera R, et al.: A doubleblind, dose-response study of midodrine in neurogenic orthostatic hypotension. Neurology 1998, 51:120–124.

    PubMed  CAS  Google Scholar 

  10. Jordan J, Shannon JR, Biaggioni I, et al.: Contrasting actions of pressor agents in severe autonomic failure. Am J Med 1998, 105:116–124.

    Article  PubMed  CAS  Google Scholar 

  11. Singer W, Opfer-Gehrking TL, McPhee BR, et al.: Acetylcholinesterase inhibition: a novel approach in the treatment of neurogenic orthostatic hypotension. J Neurol Neurosurg Psychiatry 2003, 74:1294–1298.

    Article  PubMed  CAS  Google Scholar 

  12. Ozawa T, Oyanagi K, Tanaka H, et al.: Suprachiasmatic nucleus in a patient with multiple system atrophy with abnormal circadian rhythm of arginine-vasopressin secretion into plasma. J Neurol Sci 1998, 154:116–121.

    Article  PubMed  CAS  Google Scholar 

  13. Sakakibara R, Matsuda S, Uchiyama T, et al.: The effect of intranasal desmopressin on nocturnal waking in urination in multiple system atrophy patients with nocturnal polyuria. Clin Auton Res 2003, 13:106–108.

    Article  PubMed  Google Scholar 

  14. Hoeldtke RD, Streeten DH: Treatment of orthostatic hypotension with erythropoietin. N Engl J Med 1993, 329:611–615.

    Article  PubMed  CAS  Google Scholar 

  15. Rao SV, Stamler JS: Erythropoietin, anemia, and orthostatic hypotension: the evidence mounts. Clin Auton Res 2002, 12:141–143.

    Article  PubMed  Google Scholar 

  16. Wenning GK, Geser F, Poewe W: Therapeutic strategies in multiple system atrophy. Mov Disord 2005, 20(Suppl 12):S67-S76.

    Article  PubMed  Google Scholar 

  17. van Lieshout JJ, ten Harkel AD, Wieling W: Physical maneuvers for combating orthostatic dizziness in autonomic failure. Lancet 1992, 339:897–898.

    Article  PubMed  Google Scholar 

  18. Apostolidis AN, Fowler CJ: Evaluation and treatment of autonomic disorders of the urogenital system. Semin Neurol 2003, 23:443–452.

    Article  PubMed  Google Scholar 

  19. Bemelmans BL, Mundy AR, Craggs MD: Neuromodulation by implant for treating lower urinary tract symptoms and dysfunction. Eur Urol 1999, 36:81–91.

    Article  PubMed  CAS  Google Scholar 

  20. Spinelli M, Malaguti S, Giardiello G, et al.: A new minimally invasive procedure for pudendal nerve stimulation to treat neurogenic bladder: description of the method and preliminary data.Neurourol Urodyn 2005, 24:305–309.

    Article  PubMed  Google Scholar 

  21. MacDiarmid SA, Arnold EP, Palmer NB, Anthony A: Management of spinal cord injured patients by indwelling suprapubic catheterization.J Urol 1995, 154:492–494.

    Article  PubMed  CAS  Google Scholar 

  22. Webb RJ, Lawson AL, Neal DE: Clean intermittent selfcatheterisation in 172 adults.Br J Urol 1990, 65:20–23.

    Article  PubMed  CAS  Google Scholar 

  23. Derry FA, Dinsmore WW, Fraser M, et al.: Efficacy and safety of oral sildenafil (Viagra) in men with erectile dysfunction caused by spinal cord injury.Neurology 1998, 51:1629–1633.

    PubMed  CAS  Google Scholar 

  24. Boulton AJ, Selam JL, Sweeney M, Ziegler D: Sildenafil citrate for the treatment of erectile dysfunction in men with type II diabetes mellitus.Diabetologia 2001, 44:1296–1301.

    Article  PubMed  CAS  Google Scholar 

  25. Carson CC, Lue TF: Phosphodiesterase type 5 inhibitors for erectile dysfunction.BJU Int 2005, 96:257–280. A thorough review of phosphodiesterase inhibitors.

    Article  PubMed  CAS  Google Scholar 

  26. Hussain IF, Brady CM, Swinn MJ, et al.: Treatment of erectile dysfunction with sildenafil citrate (Viagra) in parkinsonism due to Parkinson’s disease or multiple system atrophy with observations on orthostatic hypotension.J Neurol Neurosurg Psychiatry 2001, 71:371–374. An important study documenting the potential treatment complications of phosphodiesterase type 5 inhibitors in patients with underlying OH.

    Article  PubMed  CAS  Google Scholar 

  27. Dasgupta R, Wiseman OJ, Kanabar G, et al.: Efficacy of sildenafil in the treatment of female sexual dysfunction due to multiple sclerosis. J Urol 2004, 171:1189–1193.

    Article  PubMed  CAS  Google Scholar 

  28. Linet OI, Ogrinc FG: Efficacy and safety of intracavernosal alprostadil in men with erectile dysfunction. The Alprostadil Study Group. N Engl J Med 1996, 334:873–877. A large study documenting the effectiveness of alprostadil.

    Article  PubMed  CAS  Google Scholar 

  29. Lue TF: Erectile dysfunction. N Engl J Med 2000, 342:1802–1813. An extensive discussion on erectile dysfunction.

    Article  PubMed  CAS  Google Scholar 

  30. Ernst E, Pittler MH: Yohimbine for erectile dysfunction: a systematic review and meta-analysis of randomized clinical trials. J Urol 1998, 159:433–436.

    Article  PubMed  CAS  Google Scholar 

  31. Basu A, Ryder RE: New treatment options for erectile dysfunction in patients with diabetes mellitus. Drugs 2004, 64:2667–2688. A thorough review of numerous treatments.

    Article  PubMed  CAS  Google Scholar 

  32. Mirone VG, Stief CG: Efficacy of apomorphine SL in erectile dysfunction. BJU Int 2001, 88(Suppl 3):25–29.

    Article  PubMed  CAS  Google Scholar 

  33. Brinkman MJ, Henry GD, Wilson SK, et al.: A survey of patients with inflatable penile prostheses for satisfaction. J Urol 2005, 174:253–257.

    Article  PubMed  Google Scholar 

  34. Parkman HP, Hasler WL, Fisher RS: American Gastroenterological Association Medical Position Statement: Diagnosis and Treatment of Gastroparesis. Gastroenterology 2004, 127:1589–1591. A review of diagnosis and treatment of gastroparesis, with detailed discussion of all clinical trials.

    Article  PubMed  Google Scholar 

  35. Rosa-e-Silva L, Troncon LE, Oliveira RB, et al.: Treatment of diabetic gastroparesis with oral clonidine. Aliment Pharmacol Ther 1995, 9:179–183.

    Article  PubMed  CAS  Google Scholar 

  36. Thumshirn M, Camilleri M, Choi MG, Zinsmeister AR: Modulation of gastric sensory and motor functions by nitrergic and alpha2-adrenergic agents in humans. Gastroenterology 1999, 116:573–585.

    Article  PubMed  CAS  Google Scholar 

  37. Patterson DJ, Thirlby RC, Sobrino MA: High-frequency gastric stimulation in a patient with diabetic gastroparesis. Diabet Med 2004, 21:195–196.

    Article  PubMed  CAS  Google Scholar 

  38. Jones MP, Maganti K: A systematic review of surgical therapy for gastroparesis. Am J Gastroenterol 2003, 98:2122–2129.

    Article  PubMed  Google Scholar 

  39. Abrahamsson H: Gastrointestinal motility disorders in patients with diabetes mellitus. J Intern Med 1995, 237:403–409.

    Article  PubMed  CAS  Google Scholar 

  40. Harford WV, Krejs GJ, Santa Ana CA, Fordtran JS: Acute effect of diphenoxylate with atropine (Lomotil) in patients with chronic diarrhea and fecal incontinence. Gastroenterology 1980, 78:440–443.

    PubMed  CAS  Google Scholar 

  41. Hurdon V, Viola R, Schroder C: How useful is docusate in patients at risk for constipation? A systematic review of the evidence in the chronically ill. J Pain Symptom Manage 2000, 19:130–136.

    Article  PubMed  CAS  Google Scholar 

  42. Ramkumar D, Rao SS: Efficacy and safety of traditional medical therapies for chronic constipation: systematic review. Am J Gastroenterol 2005, 100:936–971.

    Article  PubMed  Google Scholar 

  43. Rao SS: Constipation: evaluation and treatment. Gastroenterol Clin North Am 2003, 32:659–683. A detailed review of constipation and its treatment.

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Autonomic and Peripheral Nerve Laboratory, Department of Neurology,Beth Israel Deaconess Medical Center, 1 Deaconess Road, 02215, Boston, MA, USA

    Roy Freeman MD

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  1. Christopher H. Gibbons MD
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  2. Roy Freeman MD
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Gibbons, C.H., Freeman, R. Treatment options for autonomic neuropathies. Curr Treat Options Neurol 8, 119–132 (2006). https://doi.org/10.1007/s11940-006-0003-0

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  • DOI: https://doi.org/10.1007/s11940-006-0003-0

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