Update on the Treatment of Autonomic Disorders

Autonomic disorders disrupt homeostasis and cause symptoms such as orthostatic hypotension, urinary urgency, bladder overfilling, sexual dysfunction, constipation, and gastroparesis. Pathophysiologic mechanisms include neurodegeneration, autoimmunity, toxic exposure, medication-induced, and an array of others. Despite the lack of disease-modifying treatments for the most common etiologies, there is a plethora of therapeutic options available to treat the manifestations of dysautonomia. Here we review established and recent therapeutic strategies available for dysautonomia. We also provide a general schema to approach the management of this class of disorders in the clinical setting.

New emerging neuromodulatory devices are showing promise in treating dysautonomic orthostatic hypotension (spinal cord stimulators), urinary dysfunction (tibial and sacral nerve stimulators), sexual dysfunction (percutaneous perineal and sacral nerve stimulation), constipation (sacral anterior root stimulation), and gastroparesis (gastric electrical stimulation). However, most of these approaches are either experimental or not yet widely implemented. Recent medications are often more effective and/or better tolerated than older ones. These include droxidopa for orthostatic hypotension, β-3-adrenergic agonists for spastic bladder, and prucalopride, elobixibat and linaclotide for constipation.

Autonomic disorders manifest with symptoms of homeostatic dysfunction. A wide variety of central and peripheral nervous system disorders cause dysautonomia. While the treatment of each specific disorder varies based on etiology, strategies overlap to manage dysautonomia. Treatments are divided into non-pharmacological, pharmacological, and neuromodulatory strategies. Here, we focus on the most common issues encountered in clinical practice and propose a stepwise approach to manage common symptoms that frequently integrates all three strategies.