AA

Pharmacological Treatments

Mrs. Miller is worried about her lightheadedness, fatigue, and numerous fainting episodes. She wonders if there is a pill she could take to make it go away.
Q4. What is the evidence for pharmacological options available to manage OH following SCI?
1. Midodrine hydrochloride should be included in the management protocol
of OH in individuals with spinal cord injury.
2. There is limited evidence that fludrocortisone, ergotamine, ephedrine, L-DOPS, and L-NAME is effective for the management of OH in SCI.
Q5. Describe the pharmophysiological effect of each of the pharmacological options available to manage OH following SCI?
1. Midodrine hydrochloride should be included in the management protocol of OH in individuals with spinal cord injury. Midodrine, a selective alpha1 adrenergic agonist, activates the alpha-adrenergic receptors of the arteriolar and venous vasculature, producing an increase in vascular tone and blood pressure.
2. There is limited evidence that fludrocortisone is effective for the management of OH in SCI. Fludrocortisone is a mineralocorticoid that causes the kidneys to retain more salt thus leading to increased water retention and plasma volume. (figure 6 shows the diagrams of location of action).
3. There is limited evidence that ergotamine is effective for the management of OH in SCI. Ergotamine, interacts with alpha adrenergic receptors and has selective vasoconstrictive effects on peripheral and cranial blood vessels.
4. There is limited evidence that ephedrine is effective for the management of OH in SCI. Ephedrine raises blood pressure both by increasing cardiac output and inducing peripheral vasoconstriction.
5. There is limited evidence that L-DOPS is effective for the management of OH in SCI. L-DOPS is a precursor of noradrenalin and acts on the brain.
Midrodrine
SCIRE found level 2 evidence that Midodrine enhances exercise performance in some individuals with SCI, similar to other clinical populations with cardiovascular autonomic dysfunction.

Fludrocortisone
There is limited evidence that fludrocortisone is effective for the management of OH in SCI according to one case series (Level 4 evidence).

Ergotamine
SCIRE found level 5 evidence that: Ergotamine, combined daily with fludrocortisone, may successfully prevent symptomatic OH. Ephedrine may prevent some symptoms of OH; that L-DOPS, in conjunction with salt supplementation may be effective for reducing OH.

For more information, please see: Pharmacological Management.

 


Figure 6.Anatomical diagram of location of action for pharmacological treatments for Orthostatic Hypotension.