Orthostatic Hypotension in Multiple System Atrophy

There is no known way to cure multiple system atrophy or even to slow its insidious progression, but there are opportunities to treat many of its symptoms and complications. Of all the autonomic disturbances it causes, orthostatic hypotension is associated with one of the better chances for successful intervention. Milder symptoms may be treated by nonpharmacologic means (eg, changes in diet and activities and compressive maneuvers and devices). Syncopal patients will require treatment with medications. Midodrine is the most effective drug. It is more physiologic and better tolerated, but much more expensive, than fludrocortisone. The latter is often beneficial but frequently causes lower limb edema. Low-dose propranolol is occasionally useful. Other drugs worth trying are indomethacin and intranasal desmopressin. The variety of measures available to treat orthostatic hypotension in multiple system atrophy affords physicians some prospect of easing the suffering of many patients with this otherwise disabling and discouraging disorder.