Autonomic Dysreflexia: Current Pharmacologic Management

PM R, 2023 · DOI: 10.1002/pmrj.13051 · Published: December 1, 2023

Spinal Cord Injury Pharmacology Neurology

Simple Explanation

Autonomic dysreflexia (AD) is a potentially dangerous complication of spinal cord injury (SCI), wherein a stimulus below the neurological level of injury causes a sympathetic cascade with resultant vasoconstriction and relative hypertension. The definition of AD is met when systolic blood pressure increases by over 20mmHg from baseline. In emergent situations, this relative hypertension can escalate to dangerous levels, with documented systolic blood pressures as high as 325mmHg. To guide management of AD, the Consortium for SCI Medicine first developed clinical practice guidelines in 1997, with iterative updates in 2002 and 2021.

Study Duration

September 2022 – April 2023

Participants

Sixty physicians managing patients with SCI

Evidence Level

Not specified

Key Findings

1
The majority of physicians (69%) had a formal AD management protocol for inpatient care, with nitroglycerin ointment (82%) being the most common first-line medication.
2
Strong national differences existed regarding the use of nitroglycerin ointment, with 98% of US-based physicians utilizing this as first line medication and 0% of physicians in Canada or Latin America utilizing this due to recent lack of medication availability.
3
Only 67% of physicians had a preferred second line medication, with preferences split between hydralazine (48%) and nifedipine (28%).

Research Summary

This study represents the first assessment of pharmacologic management of AD since the definition was formalized and clinical practice guidelines were published. Most physicians had formalized AD management protocols, with nearly ubiquitous first line use of nitroglycerin ointment when available. As of 2023, US-based physicians caring for individuals with spinal cord injury largely have formal inpatient protocols in place for medication management of autonomic dysreflexia, with 98% relying on nitroglycerin ointment as their first line medication.

Practical Implications

Nitroglycerin Ointment Availability

Advocacy efforts should focus on eliminating barriers to the use of nitroglycerin ointment outside the US to ensure optimal care for individuals with SCI.

Second-Line Medication Monitoring

Careful monitoring for hypotension is required when using second-line medications like hydralazine and nifedipine after removing the inciting stimulus of AD.

Individualized Blood Pressure Thresholds

Consider individual baselines of blood pressure (resting hypotension or essential hypertension) when determining blood pressure thresholds to initiate medication.

Study Limitations

1
The study population, while diverse in geographical locations, may not fully represent all practice patterns
2
limited samples of physicians in Canada and Latin America.
3
Not specified

Your Feedback

Was this summary helpful?

Back to Spinal Cord Injury