Therapy of Idiopathic Postural Hypotension

Abstract

The clinical response to a monamine oxidase inhibitor and a sympathomimetic amine or tyramine containing foodstuffs have been studied in four patients with idiopathic postural hypotension. Each was receiving fludrocortisone acetate therapy. One patient has had substantial clinical improvement for over 26 months on the combination and another improved symptomatically for nine months before further neurologic deterioration. One patient with additional chronic polymyositis had little change in symptoms.Another with milder manifestations of the syndrome had intolerable headaches with the therapy. Maintenance of blood volume was a necessary though not sufficient condition for symptomatic improvement with the regimen.Patients with idiopathic postural hy¬ potension are incapacitated by lightheadedness and syncope on standing, heat intolerance, decreased sweating, gastrointestinal disturb¬ ances, impotence, weakness, and easy fatigability.'-4 Perhaps the most dis¬ abling symptom in these patients, however, is their lightheadedness and syncope on standing. This orthostatic hypotension results in an inability to stand or walk and sometimes leads to severe prostration. Recently symp¬ tomatic improvement of this per¬ plexing syndrome has been reported following therapy with a combination of monoamine oxidase (MAO) inhib¬ itors and norepinephrine-releasing substances of foods containing tyramine." Ordinarily these combina¬ tions are contraindicated because of the hypertensive crises produced.7-8 However, this therapy has allowed patients with this disorder to become ambulatory and lead a more normal life.This is a report of the response to various therapeutic regimens of mono¬ amine oxidase inhibitors and indirect sympathomimetic amines in four pa¬ tients in an attempt to obtain symp¬ tomatic improvement from postural hypotension. Method of StudyFour patients comprise this study. All patients were admitted to the University Hospital or Birmingham Veterans Admin¬ istration Hospital for diagnostic and ther¬ apeutic evaluation to rule out known causes of postural hypotension and for ob¬ servation of initial therapy. Patients were weighed daily and had waking blood pres¬ sures taken every four hours supine, im¬ mediately upon standing, and five minutes after standing.Blood volume studies using iodinated I 131 serum albumin were performed ini¬ tially in two patients and repeated after unexplained weight loss occurred with ex¬ acerbation of symptoms. All patients were on a regimen of fludrocortisone (Florinef) acetate at the time of the clinical study in dosages from 0.3 to 1.0 mg plus orally ad- Fig 1.-This "stooped" posture was as¬ sumed spontaneously by patient 1 when standing still. This posture would serve to increase cerebral blood flow by improving venous return from her legs and arms and by decreasing the vertical distance from the heart to the brain. ministered potassium chloride supple¬ ments. None of the patients had been markedly improved on the regimen of fludrocortisone. A waist height elasticized garment (Jobst) had ...

Orthostatic Disorders of the Circulation

“…(1970), Lewis et al (1972), andNanda et at. (1976), with or without a monoamine oxidase inhibitor, such as tranylcypromine (Pamate, 10-20 mg tid) or phenelzine (Nardil).…”

Effect of Selected Drugs on Arterial Pressure Response to Upright Posture

“…In three cases of autonomic insufficiency, i. e., orthostatic hypotension without associated tachycardia, Lewis et al [14] reported benefit of tranylcypramine and hydroxyamphetamine combined with fluorohydrocortisone. Frewin et al [7] reported a single case in which a similar effect was pro duced by tranylcypramine, fluorohydrocortisone, and cheese, presumably on the basis of the tyramine content of the cheese.…”