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Treatment of orthostatic hypotension with indomethacin
Annotations 25.
26.
Gillingham, F. J.: The management of ruptured intracranial aneurysm, Ann. R. Coll. Surg. Engl. 2389, 1958. Vapalahuti, M., Hyyppa, M., Nieminen V., and Rinne, U. K.: Brain monoamine metabolites and tryptophan in ventricular CSF of patients with spasm after aneurysm surgery, d. Neurosurg. 48:58, 1978.
Treatment indomethacin
of orthostatic
27. 28.
hypotension
with
Orthostatic hypotension may occur as a result of volume depletion or autonomic failure. The conditions associated with volume depletion such as hemorrhage, gastrointestinal fluid loss, and Addison’s disease usually respond to fluid repletion and mineralocorticoid therapy. Autonomic failure may be responsible for postural hypotension in idiopathic orthostatic hypotension, Shy-Drager syndrome, and in certain patients with idiopathic parkinsonism.’ In the past, suggested therapy included plasma volume expansion by salt and mineralocorticoids, reduction of pooling in the legs by elastic stockings, or use of pressor drugs with or without monoamine-oxidase inhibitors. Despite these measures orthostatic hypotension secondary to autonomic failure is difficult to treat. We studied four such patients with a clinical diagnosis of Shy-Drager syndrome who had reductions in blood pressure of 20 mm. Hg or more upon standing in association with orthostatic symptoms of dizziness and fainting in addition to their neurological abnormality.’ Plasma renin activity was low in each patient and did not rise appropriately with salt restriction and diuretic stimulation. Aldosterone levels were normal and rose with diuretic therapy. Plasma volume, plasma dopamine P-hydroxylase, urinary catecholamines, metanephrines, and vanillylmandelic acid (VMA) were normal. The combination of a vasopressor (ephedrine) and a P-blocker (propranolol) was not beneficial. Two of the four patients responded to fludrocortisone with significant increase in systolic and diastolic blood pressure and with symptomatic relief of hypotension. However, all of the four gamed 1 to 2 kilograms in weight and developed dyspnea or frank congestive heart failure. On the other hand, the administration of indomethacin (75 to I50 mg./day) increased both systolic and diastolic blood pressure in all patients, relieved orthostatic symptoms, and enabled the patients to walk again. When indomethacin was discontinued in one patient after nine
Of solo
Mullan, S., and Dawley, J.: Antifibrinolytic therapy for intracranial aneurysms, J. Neurosurg. 28:21, 1968. Sengupta, R. P., So, S. C., and Villareso-Ortega, F. J.: Use of epsilon aminocaproic acid (EACA) in the preoperative management of ruptured intracranial aneurysms, J. Neurosurg. 44:479, 1976.
months of successful therapy, the blood pressure fell to pretreatment levels within 48 hours. When indomethacin was reinstituted, the blood pressure rose again within 24 hours. Indomethacin inhibits prostaglandin synthesis and several prostaglandins are potent vasodilators. Our experience raises the possibility that a relative or absolute excess of vasodilator prostaglandins may play a role in some patients with orthostatic hypotension. Recently we have found that aspirin and other inhibitors of prostaglandin synthesis can be beneficial, albeit less than indomethacin, in alleviating hypotension in two patients with orthostatic hypotension. It remains to be seen whether the salutary response to indomethacin reflects altered interrelationship between the autonomic nervous system and prostaglandins or some other mechanism. Mahendr S. Kochar, M.D., M.S., M.R.C.P. (London), F.R.C.P. (Canada), F.A.C.P. Harold D. Itskouitz, M.D., F.A.C.P. Department of Medicine James W. Albers, M.D., Ph.D. Dept. of Neurology V. A. Medical Center The Medical College of Wisconsin Wood [Milwaukee). Wise. 53193
REFERENCES 1.
2.
Davies, B., Bannister, R., and Sever, P.: Pressor amines and monoamine-oxidase inhibitors for treatment of postural hypotension in autonomic failure, Lancet i:172, 1978. Kochar, M. S., and Itskovitz, H. D.: Treatment of idiopathic orthostatic hypotension (Shy-Drager syndrome) with indomethacin, Lancet i:lOll, 1978.
practice himself. He can consult with the best consultants in the world regardless of where they are. He is not restricted to a “closed” group of physicians. He exposes himself openly to all of his associates in medicine and is viewed without prejudice or conflicts of interest. The quality of his service is reviewed by hospital services such as pathology, microbiology, practice
The rendering of excellent and unselfish service to sick people is the responsibility of all physicians. Patients always expect the best service from their doctors. The doctor who is in practice alone or with only one or two other doctors has the opportunity of rendering the best service to his patients. He is free to practice as he wishes. He collects the clinical data
0002-8703/79/080271
+ 02$00.20/O
0 1979 The
C. V. Mosby
Co.
American
Heart
Journal
271
26.
Gillingham, F. J.: The management of ruptured intracranial aneurysm, Ann. R. Coll. Surg. Engl. 2389, 1958. Vapalahuti, M., Hyyppa, M., Nieminen V., and Rinne, U. K.: Brain monoamine metabolites and tryptophan in ventricular CSF of patients with spasm after aneurysm surgery, d. Neurosurg. 48:58, 1978.
Treatment indomethacin
of orthostatic
27. 28.
hypotension
with
Orthostatic hypotension may occur as a result of volume depletion or autonomic failure. The conditions associated with volume depletion such as hemorrhage, gastrointestinal fluid loss, and Addison’s disease usually respond to fluid repletion and mineralocorticoid therapy. Autonomic failure may be responsible for postural hypotension in idiopathic orthostatic hypotension, Shy-Drager syndrome, and in certain patients with idiopathic parkinsonism.’ In the past, suggested therapy included plasma volume expansion by salt and mineralocorticoids, reduction of pooling in the legs by elastic stockings, or use of pressor drugs with or without monoamine-oxidase inhibitors. Despite these measures orthostatic hypotension secondary to autonomic failure is difficult to treat. We studied four such patients with a clinical diagnosis of Shy-Drager syndrome who had reductions in blood pressure of 20 mm. Hg or more upon standing in association with orthostatic symptoms of dizziness and fainting in addition to their neurological abnormality.’ Plasma renin activity was low in each patient and did not rise appropriately with salt restriction and diuretic stimulation. Aldosterone levels were normal and rose with diuretic therapy. Plasma volume, plasma dopamine P-hydroxylase, urinary catecholamines, metanephrines, and vanillylmandelic acid (VMA) were normal. The combination of a vasopressor (ephedrine) and a P-blocker (propranolol) was not beneficial. Two of the four patients responded to fludrocortisone with significant increase in systolic and diastolic blood pressure and with symptomatic relief of hypotension. However, all of the four gamed 1 to 2 kilograms in weight and developed dyspnea or frank congestive heart failure. On the other hand, the administration of indomethacin (75 to I50 mg./day) increased both systolic and diastolic blood pressure in all patients, relieved orthostatic symptoms, and enabled the patients to walk again. When indomethacin was discontinued in one patient after nine
Of solo
Mullan, S., and Dawley, J.: Antifibrinolytic therapy for intracranial aneurysms, J. Neurosurg. 28:21, 1968. Sengupta, R. P., So, S. C., and Villareso-Ortega, F. J.: Use of epsilon aminocaproic acid (EACA) in the preoperative management of ruptured intracranial aneurysms, J. Neurosurg. 44:479, 1976.
months of successful therapy, the blood pressure fell to pretreatment levels within 48 hours. When indomethacin was reinstituted, the blood pressure rose again within 24 hours. Indomethacin inhibits prostaglandin synthesis and several prostaglandins are potent vasodilators. Our experience raises the possibility that a relative or absolute excess of vasodilator prostaglandins may play a role in some patients with orthostatic hypotension. Recently we have found that aspirin and other inhibitors of prostaglandin synthesis can be beneficial, albeit less than indomethacin, in alleviating hypotension in two patients with orthostatic hypotension. It remains to be seen whether the salutary response to indomethacin reflects altered interrelationship between the autonomic nervous system and prostaglandins or some other mechanism. Mahendr S. Kochar, M.D., M.S., M.R.C.P. (London), F.R.C.P. (Canada), F.A.C.P. Harold D. Itskouitz, M.D., F.A.C.P. Department of Medicine James W. Albers, M.D., Ph.D. Dept. of Neurology V. A. Medical Center The Medical College of Wisconsin Wood [Milwaukee). Wise. 53193
REFERENCES 1.
2.
Davies, B., Bannister, R., and Sever, P.: Pressor amines and monoamine-oxidase inhibitors for treatment of postural hypotension in autonomic failure, Lancet i:172, 1978. Kochar, M. S., and Itskovitz, H. D.: Treatment of idiopathic orthostatic hypotension (Shy-Drager syndrome) with indomethacin, Lancet i:lOll, 1978.
practice himself. He can consult with the best consultants in the world regardless of where they are. He is not restricted to a “closed” group of physicians. He exposes himself openly to all of his associates in medicine and is viewed without prejudice or conflicts of interest. The quality of his service is reviewed by hospital services such as pathology, microbiology, practice
The rendering of excellent and unselfish service to sick people is the responsibility of all physicians. Patients always expect the best service from their doctors. The doctor who is in practice alone or with only one or two other doctors has the opportunity of rendering the best service to his patients. He is free to practice as he wishes. He collects the clinical data
0002-8703/79/080271
+ 02$00.20/O
0 1979 The
C. V. Mosby
Co.
American
Heart
Journal
271