Treatment of severe autonomic orthostatic hypotension

There remains a group in whom treatment of hypotension is unsuccessful. A recent report on a novel use of a portable norepinephrine infusion system for the therapy of severe orthostatic hypotension may point the way to an answer.6 Olaf Oldenburg and colleagues6 inserted a temporary intravenous in-dwelling catheter and an infusion pump in six people with severe orthostatic hypotension resistant to conventional methods of treatment. Blood pressure was continuously monitored and norepinephrine was given through the catheter, first with the patients supine and then standing. When this temporary infusion system was judged successful, a permanent infusion pump, via a port-a-cath system, was implanted and patients were taught to manipulate the pump in response to symptoms. They were then followed up for periods from 7 months to 5 years. Two have died, one from a brainstem infarction occurring as she stood up in the morning (without starting her infusion pump), and the second from a non-haemorrhagic stroke in a patient who whose infusion had been stopped because of non-compliance with therapy. In general, bloodpressure control was better in patients with pure autonomic failure than in those with multiple-system atrophy. There were no reports of tachyphylaxis.