Current Concepts in the Treatment of Multiple System Atrophy

Abstract

MSA is a progressive neurodegenerative disorder characterized by autonomic failure and a variable combination of poor levodopa-responsive parkinsonism and cerebellar ataxia (CA). Current therapeutic management is based on symptomatic treatment. Almost one third of MSA patients may benefit from l-dopa for the symptomatic treatment of parkinsonism, whereas physiotherapy remains the best therapeutic option for CA. Only midodrine and droxidopa were found to be efficient for neurogenic hypotension in double-blind, controlled studies, whereas other symptoms of autonomic failure may be managed with off-label treatments. To date, no curative treatment is available for MSA. Recent results of neuroprotective and -restorative trials have provided some hope for future advances. Considerations for future clinical trials are also discussed in this review.

Keywords: ataxia; atypical parkinsonism; autonomic dysfunction; multiple system atrophy; treatment.

Figure 1

Treatment algorithm for OH in MSA. *Not labeled in Europe—labeled in the United States (FDA approval in February 2014).

Figure 2

Treatment algorithm for lower urinary tract dysfunction in MSA. Detrusor hyperactivity or urethral hypertonia may be differentiated by urodynamic assessment. The postvoid residual volume should be regularly monitored, for example, with a portable ultrasound device, within 1 month after introduction of anticholinergics. CISC, clean intermittent self‐catheterization; TENS, transcutaneous electrical nerve stimulation.