Assistant Professor University of Utah SLC, Utah, United States
Case Diagnosis: Orthostatic hypotension (OH) is common after spinal cord injury (SCI), especially in complete injuries above mid-thoracic levels. OH commonly causes therapy intolerance during inpatient medical rehabilitation (IMR) and can prolong functional recovery. Despite antihypotensive agents including midodrine and fludrocortisone, maintaining blood pressure (BP) can be challenging. This case highlights the successful use of atomoxetine, traditionally used for treatment of attention deficit hyperactivity disorder, in a patient with treatment-resistant OH.
Case Description: A 65 year old female without history of BP irregularities was in a motor vehicle collision resulting in C6 AIS A on Day 0. She required vasopressor support through Day 5, followed by persistent need for midodrine 10 mg TID and fluid boluses due to symptomatic hypotension with upright activity. She began IMR on Day 13. Due to ongoing hypotension, she started fludrocortisone on Day 23, titrated to 0.2 mg daily. Her symptomatic hypotension persisted. After reviewing literature regarding therapies for other causes of hypotension, we selected atomoxetine as a safe addition, which she started on Day 28 at 10mg twice daily. Her episodes of symptomatic hypotension subsequently decreased, while her upright therapy tolerance increased. She weaned off fludrocortisone by Day 36. However, decreasing atomoxetine resulted in recurrence of symptomatic hypotension during therapies. She continued midodrine and atomoxetine on discharge.
Discussions: Atomoxetine, likely through its effects as a norepinephrine transporter blocker, increases norepinephrine in peripheral sympathetic neurons. This unique mechanism might make it a useful addition in patients similar to ours, improving SCI-related autonomic dysfunction. Careful patient selection and monitoring of side effects (eg. supine hypertension) are important when considering atomoxetine.
Conclusions: The use of atomoxetine helped to improve BP and alleviate symptoms of neurogenic OH, enhancing our patient’s therapy tolerance and improving her IMR experience. Randomized studies are needed to validate safety, efficacy and application of atomoxetine in managing neurogenic OH.
