Comparative Efficacy of Yohimbine Against Pyridostigmine for the Treatment of Orthostatic Hypotension in Autonomic Failure

@article{Shibao2010ComparativeEO,
  title={Comparative Efficacy of Yohimbine Against Pyridostigmine for the Treatment of Orthostatic Hypotension in Autonomic Failure},
  author={Cyndya A. Shibao and Luis E. Okamoto and Alfredo Gamboa and Chang Yu and Andr{\'e} Diedrich and Satish R. Raj and David Robertson and Italo Biaggioni},
  journal={Hypertension},
  year={2010},
  volume={56},
  pages={847-851}
}
Orthostatic hypotension affects patients with autonomic failure producing considerable disability because of presyncopal symptoms. Severely affected patients may have residual sympathetic tone that can be engaged to increase blood pressure (BP) with the &agr;-2 adrenergic antagonist yohimbine. This medication activates sympathetic outflow centrally and unrestrains norepinephrine release from noradrenergic neurons. Alternatively, the acetylcholinesterase inhibitor, pyridostigmine, can increase… 

Figures and Tables from this paper

Synergistic Pressor Effect of Atomoxetine and Pyridostigmine in Patients With Neurogenic Orthostatic Hypotension
TLDR
The combination pyridostigmine and atomoxetine had a synergistic effect on seated BP which was associated with improvement in orthostatic tolerance and symptoms and could be useful in patients with severe autonomic failure.
Combination ergotamine and caffeine improves seated blood pressure and presyncopal symptoms in autonomic failure
TLDR
It is suggested that combination ergotamine and caffeine elicits a seated pressor response that is similar in magnitude to midodrine, and improves symptoms in autonomic failure, and could be used as an alternate treatment for autonomic Failure, in carefully selected patients without comorbid coronary artery disease.
Chemical pharmacotherapy for the treatment of orthostatic hypotension
  • W. Cheshire
  • Medicine, Biology
    Expert opinion on pharmacotherapy
  • 2019
TLDR
This review summarizes and critiques established and emerging pharmacologic approaches for the management of neurogenic orthostatic hypotension and suggests the selective use of several off-label drugs in difficult cases.
Diagnosing and treating neurogenic orthostatic hypotension in primary care
TLDR
Concerns about supine hypertension – for which the long-term prognosis in patients with NOH is yet to be established – must sometimes be balanced by the need to address a patient’s immediate risks.
Droxidopa for the treatment of neurogenic orthostatic hypotension and other symptoms of neurodegenerative disorders
TLDR
Results from a few small and short placebo-controlled trials and clinical studies in neurogenic OH showed significant reductions in the manometric drop of blood pressure after posture changes or meals, but larger Phase III studies suggest a positive effect of the drug on dizziness.
Orthostatic Hypotension: JACC State-of-the-Art Review.
Advances in the Pathophysiology and Management of Supine Hypertension in Patients with Neurogenic Orthostatic Hypotension
TLDR
Novel approaches, such as the use of local heat can control nighttime sHTN, reduce nocturia, and improve OH, and recent findings offer hope that it can treat nocturnal s HTN and at the same time improve daytime OH, lessening the controversy whether to treat or not sHTn.
Efficacy of single or combined midodrine and pyridostigmine in orthostatic hypotension
TLDR
This study provides Class IV evidence that for patients with neurogenic OH, long-term treatment with midodrine alone, pyridostigmine alone, or both midodine and pyridine is safe and has similar effects in improving orthostatic BP drop up to 3 months.
...
...

References

SHOWING 1-10 OF 27 REFERENCES
Pyridostigmine treatment trial in neurogenic orthostatic hypotension.
TLDR
Pyridostigmine significantly improves standing BP in patients with OH without worsening supine hypertension, suggesting that the improvement is due to increased total peripheral resistance.
Oral yohimbine in human autonomic failure
TLDR
Yohimbine may be useful in the treatment of orthostatic hypotension associated with autonomic failure and enhances discharge of the patient's own sympathetic system, unique among current modes of therapy for this disorder.
Acetylcholinesterase inhibition: a novel approach in the treatment of neurogenic orthostatic hypotension
TLDR
This novel approach to treatment using acetylcholinesterase inhibition appears effective in the treatment of neurogenic orthostatic hypotension, specially for patients with a high supine blood pressure.
Treatment of orthostatic hypotension due to autonomic failure with a peripheral alpha‐adrenergic agonist (midodrine)
TLDR
It is concluded that midodrine is effective in the treatment of orthostatic hypotension only in those patients with significant preservation of autonomic reflexes, and in patients with markedly impaired baroreceptor mechanisms, treatment withmidodrine may produce extracellular fluid volume depletion and exacerbate orthostatics.
Manipulation of Norepinephrine Metabolism with Yohimbine in the Treatment of Autonomic Failure
TLDR
Yohimbine is not only a useful tool in the study of blood pressure regulation, but may offer a therapeutic option in autonomic dysfunction because patients with autonomic failure, even those with severe sympathetic deprivation, are hypersensitive to the pressor effects of yOHimbine.
A double-blind, dose-response study of midodrine in neurogenic orthostatic hypotension
TLDR
A 10-mg dose of midodrine prescribed two to three times daily is effective in increasing orthostatic blood pressure and ameliorating symptoms in patients with NOH.
Treatment of orthostatic hypotension.
TLDR
Most patients can be treated successfully with volume expansion or fludrocortisone or both in combination with a sympathomimetic agent, and a small group of patients remain refractory to all therapeutic modalities.
Mineralocorticoid-induced hypertension in patients with orthostatic hypotension.
TLDR
Clinically, hypertension in the recumbent position is an important risk of fludrocortisone treatment in patients with orthostatic hypotension, and this unusual model of chronic mineralocorticoid-induced hypertension is not volume dependent but is related to increased peripheral-vascular resistance.
...
...