Pharmacological Management of AD
Episodes of AD in people 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 and so 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 if non-pharmacological measures fail and arterial blood pressure remains at 150 mmHg or greater (Blackmer, 2003; Consortium for Spinal Cord Medicine, 2001). However, while numerous pharmacological agents (e.g., nifedipine, nitrates, captopril, terzaosin, prazosin, phenoxybenamine, Prostaglandin E2, sildanefil) have been proposed for management of AD (Consortium for Spinal Cord Medicine, 2001; Blackmer, 2003; Naftchi & Richardson 1997), the Consortium for Spinal Cord Medicine (2001) does not identify any particular medication as the standard. A survey by Solinsky (2023) found that of 60 physicians who treated patients with SCI, 82% used nitroglycerin ointment as a first-line medication when conservative treatments failed. Moreover, 67% of physicians had explicit second-line medications to manage AD, commonly hydralazine (48%), nifedipine (28%), prazosin (5%), and clonidine (5%) (Solinsky, 2023). Additionally, the majority of the recommendations are based on the clinical management of hypertensive crises in populations without SCI, 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 populations without SCI, there is a clinical need for immediate action in individuals with SCI due to the mechanisms of hypertensive crisis and the risk of intracranial bleed, myocardial infarction, or death (Ho & Krassioukov 2010; Yoo et al. 2010). Episodes of AD are typically short-lasting events; thus, they could be well controlled with the use of fast-acting antihypertensive medications. Therefore, the use of these medications for the management of hypertension is less likely to result in the deleterious effects observed in populations without SCI, provided that it is given at a low dose and only as needed.
