Management of Hypotension and Bradycardia Caused by Spinal Cord Injury. The Usefulness of Midodrine and Methylxanthines

Document Type : Case Report

Authors

1 Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran.

2 Department of Anesthesiology and Intensive Care, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran.

3 Department of Clinical Pharmacy, Faculty of Pharmacy, Gilan University of Medical Sciences, Rasht, Iran.

Abstract

Spinal cord injury is a devastating chronic condition resulting in temporary or permanent motor,
sensory or autonomic dysfunction of the cord. The manifestation of spinal cord injury based on
the severity and involved areas could be different. Numerous studies have demonstrated that
bradycardia, hypotension, and orthostatic hypotension are present insignificant number of
patients after spinal cord injury which peaks at 4th day of injury. Although vasopressors are
common drugs that have been used to restore blood pressure and heart rate in patients with
neurogenic shock, there is limited data regarding pharmacologic management of bradycardia and
hypotension after spinal cord injury. Midodrine is a potent vasopressor approved for the
management of symptomatic orthostatic hypotension. Theophylline and aminophylline are
methylxanthine derivatives. There are very few case reports concerning the use of midodrine and
methylxanthines for treatment of hypotension in patients with spinal cord injury. In this case
report and review of the articles we report a 45 year old woman with a diagnosis of spinal cord
injury who was successfully managed with midodrine and aminophylline and then we review
current case reports. Based on our case report and other available data, midodrine as well as
methylxanthines can be suggested as therapeutic options for managing symptoms in spinal cord
injury patients.

Keywords

Main Subjects


References
Spinal Cord Injury Facts and Figures at a Glance, The
National SCI Statistical Center, https://www.nscisc.
uab.edu/reports.aspx, (2017).
Sadaka F, Naydenov SK and Ponzillo JJ. Theophylline
for bradycardia secondary to cervical spinal cord
injury. Neurocrit. Care (2010) 13: 389–92.
Krassioukov A, Eng JJ, Warburton DE and Teasell
R. Spinal cord injury rehabilitation evidence research
team. A systematic review of the management of
orthostatic hypotension after spinal cord injury. Arch.
Phys. Med. Rehabil. (2009) 90: 876-85.
Fehlings MG, Tetreault LA, Wilson JR, Kwon BK,
Burns AS, Martin AR, Hawryluk G and Harrop JS.
A Clinical practice guideline for the management of
(1)
(2)
(3)
(4)
acute spinal cord injury: introduction, rationale, and
scope. Global Spine J. (2017) 7: 84-94
Pasnoori VR and Leesar MA. Use of aminophylline
in the treatment of severe symptomatic bradycardia
resistant to atropine. Cardiol. Rev. (2004) 12: 65-8.
Schulz-Stübner S. The use of small-dose theophylline
for the treatment of bradycardia in patients with spinal
cord injury. Anesth. Analg. (2005) 101: 1809-11.
Sakamoto T, Sadanaga T and Okazaki T. Sequential use
of aminophylline and theophylline for the treatment of
atropine-resistant bradycardia after spinal cord injury:
a case report. J. Cardiol. (2007) 4: 91-6.
Whitman CB, Schroeder WS, Ploch PJ and
Raghavendran K. Efficacy of aminophylline for
treatment of recurrent symptomatic bradycardia after
spinal cord injury. Pharmacotherapy (2008) 28: 131-5.
Weant KA, Kilpatrick M and Jaikumar S.
Aminophylline for the treatment of symptomatic
bradycardia and asystole secondary to cervical spine
injury. Neurocrit. Care (2007) 7: 250–2.
Nieshoff EC, Birk TJ, Birk CA, Hinderer SR and
Yavuzer G. Double-blinded, placebo-controlled trial
of midodrine for exercise performance enhancement in
tetraplegia: a pilot study. J. Spinal Cord Med. (2004)
27: 219-25.
Senard JM, Arias A, Berlan M, Tran MA, Rascol A and
Montastruc JL. Pharmacological evidence of alpha 1-
and alpha 2-adrenergic supersensitivity in orthostatic
hypotension due to spinal cord injury: a case report.
Eur. J. Clin. Pharmacol. (1991) 41: 593-6.
Barber DB, Rogers SJ, Fredrickson MD and Able
AC. Midodrine hydrochloride and the treatment of
orthostatic hypotension in tetraplegia: two cases and
a review of the literature. Spinal Cord (2000) 38:
109-11.
Mukand J, Karlin L, Barrs K and Lublin P. Midodrine
for the management of orthostatic hypotension in
patients with spinal cord injury: A case report. Arch.
Phys. Med. Rehabil. (2001) 82: 694-6.
Wecht JM, Rosado Rivera D, Handrakis JP, Radulovic
M and Bauman WA. Effects of midodrine hydrochloride
on blood pressure and cerebral blood flow during
orthostasis in persons with chronic tetraplegia. Arch.
Phys. Med. Rehabil. (2010) 91: 1429-35.
Phillips AA, Krassioukov AV, Ainslie PN and
Warburton DE. Perturbed and spontaneous regional
cerebral blood flow responses to changes in blood
pressure after high-level spinal cord injury: the effect
of midodrine. J. Appl. Physiol. (2014) 116: 645-53.