Treatment of neurogenic orthostatic hypotension with a monoamine oxidase inhibitor and tyramine

Abstract

Six patients with neurogenic orthostatic hypotension were treated with a chemical preparation of tyramine and tranylcypromine ("Parnate"), a monoamine oxidase inhibitor (M.A.O.I.). Four had autonomic failure with no other neurological deficit (idiopathic orthostatic hypotension), and in two patients other neuronal systems were also involved (Shy-Drager syndrome). Previous therapy with fludrocortisone, ephedrine, elastic garments, postural training, and, in one patient, an anti-G suit was unsatisfactory. Tyramine given orally with tranylcypromine produced a moderate rise in blood-pressure which was sustained for 2-4 hours, enabling patients to walk about without symptoms of orthostatic hypotension. Measurement of circulating adrenaline and noradrenaline during therapy suggested that release of noradrenaline caused the pressor response. In three patients there has been a pronounced improvement for 8, 20 and 30 months. In a further patient, therapy has been successful in treating the orthostatic hypotension, although his mobility has been restricted by cerebellar ataxia. In one patient a confusional state developed during treatment and therapy was stopped. The only patient in whom the drugs did not produce a pressor response had orthostatic hypotension with failure of noradrenaline release. It is suggested that the pressor response to a M.A.O.I. and tyramine should be examined in patients with neurogenic orthostatic hypotension and that this treatment should be tried in those who respond.