Peripheral autonomic failure - Treatment

Treatment of peripheral autonomic failure is symptomatic and is a rather difficult task for a physician. Treatment of many manifestations of peripheral autonomic failure has not yet been sufficiently developed. We will touch upon the issues of treatment of the most severe disorders that maladaptive patients.

Treatment of orthostatic hypotension. There are two principles in the treatment of orthostatic hypotension. One is to limit the volume that can be occupied by blood when taking a vertical position, the other is to increase the volume of circulating blood. As a rule, complex treatment is used. First of all, the patient should be given advice on the rules for preventing orthostatic disorders. To prevent arterial hypertension in the supine position and a sharp drop in blood pressure when getting up in the morning, it is recommended to give a higher position to the head and upper body during sleep. Food should be taken in small portions, but more often (5-6 times a day). To increase the volume of circulating fluid, it is recommended to consume table salt up to 3-4 g / day and liquid up to 2.5-3.0 l / day (400 ml during meals and 200-300 ml between meals). The appearance of small edema is usually well tolerated by patients and helps maintain blood pressure. When the first signs of fainting appear, it is advisable to do one or more squats; if it is necessary to stand for a long time, it is recommended to cross your legs and shift from foot to foot. These simple techniques promote mechanical compression of the peripheral vessels and prevent blood from depositing in them and, accordingly, reducing systemic arterial pressure. For the same purpose, tight bandaging of the lower extremities, pelvic girdle, abdomen; wearing elastic stockings (tights), antigravity suits are used for treatment. Patients are recommended to swim, ride a bicycle, and go for walks. In general, isotonic physical activity is more preferable than isometric. Patients should be warned about situations that adversely affect blood pressure and contribute to its reduction: alcohol consumption, smoking, prolonged lying down, eating large amounts of food, staying in hot conditions, hyperventilation, sauna.

Drug treatment involves the use of drugs that increase the volume of circulating fluid, increase the endogenous activity of the sympathetic nervous system and promote vasoconstriction, blocking vasodilation.

The most effective drug with the above properties is a-fludrocortisone (Florinef) from the mineralocorticoid group. It is prescribed at 0.05 mg 2 times a day, with a gradual increase if necessary by 0.05 mg per week to a daily dose of 0.3-1.0 mg.

With great caution, taking into account the phenomenon of arterial hypertension in the supine position, alpha-adrenergic agonists are prescribed, the main effect of which is vasoconstriction of peripheral vessels. Such drugs include midodrine (Gutron): 2.5-5.0 mg every 2-4 hours, maximum up to 40 mg/day, methylphenidate (Ritalin): 5-10 mg 3 times a day 15-30 minutes before meals, the last dose no later than 18.00, phenylpropanolamine (Propagest): 12.5-25.0 mg 3 times a day, increasing if necessary to 50-75 mg/day. It is necessary to ensure that the arterial pressure in the supine position does not increase to 200/100 mm Hg. Art., positive in the treatment of orthostatic hypotension is arterial pressure in the supine position within the range of 180/100-140/90 mm Hg. Art. Also used are preparations containing ephedrine, ergotamine. The ability to increase arterial pressure has the drug Regulton (amesinia methylsulfate), prescribed in such cases 10 mg 13 times a day. Also, in order to increase arterial pressure, sometimes it is enough to drink coffee (2 cups) or caffeine 250 mg in the morning.

In order to reduce and prevent peripheral vasodilation in patients with orthostatic hypotension, the following drugs have been used: beta-blockers (obzidan: 10-40 mg 3-4 times a day, pindolol (visken): 2.5-5.0 mg 2-3 times a day), non-steroidal anti-inflammatory drugs (aspirin: 500-1500 mg/day, indomethadine 25-50 mg 3 times a day, ibuprofen 200-600 mg 3 times a day during meals). Cerucal (metoclopramide (reglan): 5-10 mg 3 times a day) has the same property.

Recently, there have been reports of the effectiveness of erythropoietin (a glucoprotein hormone related to growth factors that stimulate erythropoiesis and have a sympathomimetic effect) in the treatment of orthostatic hypotension, used in such cases at a dose of 2000 IU subcutaneously 3 times a week, for a total of 10 injections.

Clonidine, histamine receptor antagonists, yohimbine, desmopressin, and MAO inhibitors have also been proposed for the treatment of orthostatic hypotension. However, due to serious side effects, their use is currently extremely limited.

Treatment of urination disorders in peripheral autonomic failure is an extremely difficult task. To increase detrusor contractility, the cholinergic drug aceclidine (betanicol) is used. In atonic bladder, the use of aceclidine in a dose of 50-100 mg/day leads to an increase in intravesical pressure, a decrease in bladder capacity, an increase in the maximum intravesical pressure at which urination begins, and a decrease in the amount of residual urine. A certain effect can be obtained by prescribing alpha-adrenergic agonists such as phenylpropanolamine (50-75 mg 2 times a day) to improve the functions of the internal sphincter. For the same purpose, melipramine is sometimes prescribed at 40-100 mg/day. The addition of urinary infection requires immediate antibiotic therapy. In addition to drugs, it is recommended to use mechanical compression of the anterior abdominal wall, electrical stimulation of the pelvic floor muscles. Of course, if drug therapy is ineffective, bladder catheterization is performed. In case of severe urination disorders, which rarely occurs with peripheral autonomic insufficiency, resection of the bladder neck is performed. Urine retention remains possible due to the intactness of the external sphincter, which has somatic innervation.

Treatment of gastrointestinal disorders. In case of insufficient motor function of the gastrointestinal tract, it is recommended to eat easily digestible food (low fat, fiber), in small portions. Regular laxatives can also be effective. Drugs with cholinomimetic properties (such as aceclidine) are also indicated. Recently, attempts have been made to use the method of biological feedback and electrical stimulation of the spinal roots of the spinal cord to treat peripheral autonomic insufficiency in the gastrointestinal system.

Treatment of impotence in peripheral autonomic failure. The use of alpha-1-adrenoblocker yohimbine is recommended. In addition, papaverine and nitroglycerin can be used. However, side effects when using the latter limit their widespread use. Drug treatment is usually ineffective, and therefore patients often use various mechanical prostheses. Sometimes reconstructive operations on vessels are performed, ensuring normal vascularization of the penis.

Usually, the low efficiency of treatment of peripheral autonomic failure syndromes is aggravated by underestimation of their clinical manifestations or inadequate clinical interpretation. Knowledge of the clinical manifestations of peripheral autonomic failure, as well as methods of its diagnosis (this is especially true for the cardiovascular system), undoubtedly opens up prospects for more successful correction of these disorders, thereby improving the prognosis of peripheral autonomic failure.

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Prognosis of peripheral autonomic failure

Timely detection of symptoms of peripheral autonomic failure is important primarily from the point of view of disease prognosis. Numerous studies of peripheral autonomic failure in diabetes mellitus, as well as in Guillain-Barré syndrome, alcoholism, Shy-Drager syndrome, etc. have demonstrated that the presence of peripheral autonomic failure syndrome in a patient is a poor prognostic sign. Thus, when studying patients with diabetes mellitus, it was shown that patients suffering from peripheral autonomic failure die within 5-7 years, with half of them dying in the first 2.5 years. Possible causes of death include painless myocardial infarction, cardiac tachyarrhythmia, "cardiorespiratory arrests", and sleep apnea. Thus, the detection of peripheral autonomic failure in a patient requires increased attention from doctors and nursing staff to the management of the patient, the selection of adequate medications, and consideration of the impact of the pharmaceuticals used on various autonomic functions.