Pharmacological Management of AD

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Episodes of AD in individuals with SCI can vary in severity, but in some cases can be asymptomatic and be managed by the individual once they are familiar with their own triggers and symptoms (Linsenmeyer et al. 1996).  However, in some individuals it is difficult to find the trigger for the acute blood pressure elevation and immediate medical attention is required (Elliott & Krassioukov 2006). Antihypertensive drugs with a rapid onset and short duration of action should be used in the management of acute episodes (Blackmer 2003). The Consortium for Spinal Cord Medicine recommends that if non-pharmacological measures fail and arterial blood pressure remains 150 mmHg or greater, pharmacological management should be initiated (Consortium for Spinal Cord Medicine 2001). However, the Consortium for Spinal Cord Medicine (2001) does not identify any particular medication for management of AD. Numerous pharmacological agents (e.g. nifedipine, nitrates, captopril, terzaosin, prazosin, phenoxybenamine, Prostaglandin E2, sildanefil) have been proposed for management of episodes of AD (Consortium for Spinal Cord Medicine; Blackmer 2003; Naftchi & Richardson 1997). The majority of the recommendations are based on the clinical management of hypertensive crises in able-bodied populations, as well as case reports and anecdotal evidence.  Characteristics and outcomes of studies assessing pharmacological interventions for the management of AD are presented in the following sections.

The literature supporting pharmacological management of AD using fast-acting antihypertensive drugs is specific to SCI.  Although the use of fast-acting anti-hypertensives is strongly discouraged in able-bodied populations, there is a clinical need for immediate action in individuals with SCI, due to the mechanisms of hypertensive crisis and a result of the emergent risk of intracranial bleed, myocardial infarction or death (Ho & Krassioukov 2010; Yoo et al. 2010). Episodes of AD are typically short lasting events, and could thus be well controlled with the use of short acting antihypertensive medications. Therefore, the use of these medications at a low dose and only as needed is less likely to result in the deleterious effects observed in the able bodied population when initially prescribed for the management of hypertension.