Table 2.
Symptomatic therapies in MSA
| Symptom | Pharmacologic therapy | Nonpharmacologic therapy |
|---|---|---|
| Parkinsonism |
Carbidopa/levodopa commonly to 200 to 300 mg × 3-4 times daily, 2000 mg daily max Amantadine up to 100 mg × 3 times daily |
Physical therapy (PT) Occupational therapy (OT) Regular activity, exercise |
| Dystonia | Trihexyphenidyl, botulinum toxin | PT and OT |
| Spasticity |
Muscle relaxants (e.g., baclofen, tizanidine) Botulinum toxin |
PT and OT |
| Dysarthria | – | Speech therapy |
| Dysphagia | – | SLP swallow evaluation, therapy |
| Autonomic failure | ||
| Orthostatic hypotension |
Fludrocortisone 0.1-0.4 mg daily Midodrine 2.5 to 10 mg × 3 times daily Droxidopa 100 to 600 mg × 3 times daily Pyridostigmine 60 mg × 3 times daily Atomoxetine 18 mg daily Caffeine |
Hydration, fluid intake Increased dietary salt Abdominal binders Waist-high compression stockings |
| Postprandial hypotension |
Octreotide 25–50 mcg before meals Acarbose 25–50 mg before meals |
Eat smaller, more frequent meals Avoid high-carbohydrate meals Avoid alcohol Remain seated (or lie down) after eating |
| Supine hypertension |
Nightly clonidine 0.1-0.3 mg Hydralazine 25-50 mg, minoxidil 2.5 mg Losartan 25 mg Nifedipine 10-20 mg Nitroglycerin TD (wipe off in AM) Sildenafil 25 mg |
Assess scheduled medications Elevate head of bed Bedtime snack (postprandial effect) |
| Urge incontinence |
Solifenacin, trospium Mirabegron |
Timed urination Intermittent self-catheterization Suprapubic catheter placement |
| Incomplete bladder emptying |
Tamsulosin 0.4 mg daily Prazosin 0.5-1 mg twice daily |
|
| Sialorrhea | Botulinum toxin |
Sugar-free lozenges, gum Papaya or grape seed extract |
| Nocturia | Desmopressin 0.2-0.6 mg nightly | No fluids 3-4 h before bed |
| Constipation |
Stool softeners Senna, laxatives, enemas Polyethylene glycol 3350 Magnesium citrate Linaclotide Lubiprostone |
Increased fluid, fiber intake Activity/exercise |
| Erectile dysfunction |
Sildenafil 50-100 mg prn Tadalafil 5-20 mg prn Vardenafil 5-20 mg prn Apomorphine subq injections Prostaglandin E1 or paperverine intercavernous injections |
Implants |
| Sleep disorders | ||
| REM-behavior disorder |
Melatonin extended release 3-15 mg nightly Clonazepam 0.25-2 mg nightly |
|
|
Restless leg syndrome (or RLS/PLMS) |
Dopamine agonists: Pramipexole 0.125-0.5 mg, ropinirole 0.25-4 mg, or rotigotine TD 2-6 mg/24 h Gabapentin versus gabapentin enacarbil Benzodiazepines (i.e., clonazepam)—relative contraindication in sleep apnea |
|
| Nocturnal stridor |
Botulinum toxin injection (dystonic stridor)* Minimally invasive procedures*† |
First line—ventilation with CPAP Persistent/severe—consider tracheostomy |
| Sleep apnea | – |
Change in sleep position, weight loss Oral appliance therapy CPAP versus AutoPAP (if central) Uvulopalatopharyngoplasty Neurostimulation |
| Neuropsychiatric symptoms | ||
| Depression | SSRIs/SNRIs |
Psychotherapy Cognitive behavioral therapy |
| Anxiety |
Anxiolytics, benzodiazepines Buspirone |
|
| Pseudobulbar affect | Dextromethorphan/quinidine | |
*Insufficient evidence to support treatment
†E.g., airway dilation, arytenoidectomy, cordectomy