Peripheral autonomic failure: treatment

Treatment of peripheral autonomic failure is symptomatic and is a rather difficult task for the doctor. Treatment of many manifestations of peripheral vegetative insufficiency has not been sufficiently developed. We will touch on the treatment of the most severe, maladaptive disorders.

Treatment of orthostatic hypotension. In the treatment of orthostatic hypotension, there are two principles. One is to limit the volume that can be occupied by blood when taking the 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 the prevention of orthostatic disorders. To prevent arterial hypertension in the prone position and a sharp fall in blood pressure on rising in the morning, it is recommended to give a higher position to the head and upper body during sleep. Take food should be in small portions, but more often (5-6 times a day). To increase the volume of circulating fluid, use of table salt is recommended up to 3-4 g / day. And liquids up to 2.5-3.0 l / day. (400 ml at meal time and 200-300 ml between meals). The appearance of small edema, as a rule, is well tolerated by patients and helps maintain blood pressure. When the first pre-occult manifestations appear, it is advisable to do one or several sit-ups; 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 contribute to the mechanical compression of peripheral vessels and prevent the deposition of blood in them and, accordingly, decrease in systemic arterial pressure. With the same purpose for the treatment use of tight bandaging of the lower extremities, pelvic girdle, abdomen; wearing elastic stockings (pantyhose), anti-gravity suits. Patients are recommended swimming, cycling, walking. In general, isotonic exercise is more preferable than isometric exercise. It is necessary to warn patients about situations that adversely affect blood pressure and contribute to its reduction: alcohol consumption, smoking, long lying, 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 group of mineralocorticoids. Assigned to 0.05 mg 2 times a day, with a gradual, if necessary, an increase of 0.05 mg per week to a daily dose of 0.3-1.0 mg.

With great care, taking into account the phenomenon of arterial hypertension in the prone position, a-adrenomimetics is prescribed, the main effect of which is vasoconstriction of peripheral vessels. These drugs include midodrin (gutron): 2.5-5.0 mg every 2-4 hours, a maximum of 40 mg / day, methylphenidate (Ritalin): 5-10 mg 3 times a day for 15-30 minutes before meals, the last reception no later than 18.00, phenylpropanolamine (propagest): 12,5-25,0 mg 3 times a day, increasing if necessary up to 50-75 mg / day. It should be ensured that the blood pressure in the supine position does not increase up to 200/100 mm Hg. St, positive in the treatment of orthostatic hypotension is the arterial pressure in the supine position within 180 / 100-140 / 90 mm Hg. Art. Use also drugs containing ephedrine, ergotamine. The ability to increase blood pressure has a drug regulton (amezinia methyl sulfate), prescribed in such cases 10 mg 13 times a day. Also in order to increase blood pressure, it is sometimes sufficient to take coffee (2 cups) or caffeine 250 mg in the morning.

To reduce and prevent peripheral vasodilation in patients with orthostatic hypotension, drugs such as beta-adrenoblockers (obzidan: 10-40 mg 3-4 times a day, pindolol (vecin): 2.5-5.0 mg 2-3 once 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 (raglan) has the same property: 5-10 mg 3 times a day).

Recently, there have been reports of efficacy in the treatment of orthostatic hypotension of erythropoietin (a glucoprotein hormone related to growth factors, stimulating erythropoiesis, which has a sympathomimetic effect) used in such cases at a dose of 2000 U / ml 3 times a week, with a total of 10 injections.

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

Treatment of micturition disorders in peripheral autonomic failure is an extremely difficult task. To increase the detrusor contractility, the cholesteric drug ateclidine (betanikol) is used. With an atonic bladder, the use of acetylidine in a dose of 50-100 mg / day. Leads to an increase in intravesical pressure, a decrease in the capacity of the bladder, an increase in the maximum intravesical pressure at which urination begins, and a decrease in the amount of residual urine. A definite effect can be obtained with the appointment of alpha-adrenomimetics such as phenylpropanolamine (50-75 mg 2 times a day) to improve the functions of the internal sphincter. For the same purpose, sometimes prescribed melipramine 40-100 mg / day. Joining of the infection requires immediate antibiotic therapy. In addition to medicines, it is recommended to use mechanical compression of the anterior abdominal wall, electrostimulation of the muscles of the pelvic floor. Of course, if the drug therapy is ineffective, catheterization of the bladder is performed. At the grossest violations of urination, which rarely happens in peripheral vegetative insufficiency, a resection of the neck of the bladder is performed. Urinary retention remains possible due to the intactness of the external sphincter, which has a somatic innervation.

Treatment of gastrointestinal disorders. When the motor function of the gastrointestinal tract is inadequate, the use of easily assimilated food (low fat, fiber) is recommended, in small portions. There are effective and usual laxatives. Also shown are drugs that have a cholinomimetic property (such as acetylidine). Recently, attempts have been made to use the biofeedback method, electrostimulation of the spinal roots of the spinal cord, to treat peripheral vegetative insufficiency in the gastrointestinal system.

Treatment of impotence in peripheral autonomic failure. Recommend the use of alpha-1-adrenoblocker yohimbine. In addition, papaverine, nitroglycerin can be used. However, side effects in the use of the latter make them widely used. Drug treatment, as a rule, is ineffective, and therefore patients often use various mechanical prostheses. Sometimes reconstructive operations on the vessels, providing a normal vascularization of the penis, are performed.

Usually, the low effectiveness of treatment of peripheral vegetative insufficiency syndromes is aggravated by underestimation of their clinical manifestations or inadequate clinical interpretation. Knowledge of the clinical manifestations of peripheral vegetative insufficiency, as well as the methods of its diagnostics (especially this applies to the cardiovascular system) undoubtedly opens the prospect for a more successful correction of these disorders, thereby helping to improve the prognosis of peripheral autonomic failure.

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Prognosis of peripheral vegetative insufficiency

Timely detection of peripheral vegetative insufficiency symptoms is important primarily in terms of disease prognosis. In numerous studies of peripheral vegetative insufficiency in diabetes mellitus, as well as Guillain-Barre syndrome, alcoholism, Shy-Drager syndrome, etc., it was demonstrated that the patient's syndrome of peripheral vegetative insufficiency is a poor prognostic sign. Thus, in the study of patients with diabetes mellitus it was shown that patients suffering from peripheral vegetative insufficiency die within 5-7 years, half of them dying in the first 2.5 years. Among the possible causes of death are painless myocardial infarction, cardiac tachyarrhythmias, "cardiorespiratory arrest," sleep apnea. Thus, revealing a peripheral vegetative insufficiency in a patient requires increased attention on the part of doctors and nurses to the management of the patient, the selection of adequate medicines, the accounting of the effect of the pharmacological drugs used on various vegetative functions.