Guide to dysautonomia treatment

From my wiki, there’s a summary of a treatment guide for dysautonomia. It’s a very conventional mainstream-friendly approach so you should be able to take it to any doctor.

Bisaccia, Ricci, Fedorowski, Gallina, and colleagues / dysautonomia treatments

This group published a review paper on PASC / long COVID. It discusses dysautonomia treatment:

Key treatments (for dysautonomia): Non-pharmacological measures should be considered as first-line treatment options

  • physical reconditioning with aerobic progressive exercise training programs
  • compression garments / stockings
  • liberal intake of water and salt
  • drinking water before getting up in the morning
  • sleeping with the head of the bed elevated
  • careful avoidance of situations that can exacerbate symptoms (sleep deprivation, heat exposure, alcohol intake, or large or heavy meals)
  • Physical maneuvers such as leg crossing, muscle tensing, and squatting have been shown to be effective in delaying/preventing vasovagal syncope if used at the onset of prodromal symptoms.

Pharmacological therapies have been frequently used in PASC patients (see Table 3 in their paper). These should be reserved for patients which do not respond to nonpharmacological therapies and are complementary to nonpharmacological measures in patients with severe, refractory symptoms. Recommended drugs have also been extensively used where symptoms persist. These include:

  • volume expanders (fludrocortisone, desmopressin, and intravenous saline)
  • heart rate inhibitors (propranolol, ivabradine, and pyridostigmine)
  • vasoconstrictors (midodrine, octreotide, methylphenidate, and droxidopa)
  • sympatholytic drugs (clonidine and methyldopa)

Decisions regarding which treatment to initiate should be guided by specific symptoms and hemodynamic patterns, i.e., tachycardic vs. hypotensive phenotypes.

The tachycardic phenotype can be treated with beta-blockers, i.e., metoprolol, or ivabradine. Recently, intravenous metoprolol has been tested for use in the treatment of acute respiratory distress in acute COVID-19 and was found to improve oxygenation and reduce alveolar inflammation, shortening the duration of invasive mechanical ventilation overall [92]. Large-scale randomized evidence is eagerly awaited to [figure out if the drug is helpful or not].

In patients with the hypotensive phenotype, droxidopa, midodrine, or pyridostigmine may be considered. In hypovolemic patients, intravenous saline infusion and intravascular volume expansion would be highly desirable, while the use of fludrocortisone and desmopressin should be reserved to patients with severe refractory symptoms. Sympatholytic drugs, such as clonidine and methyldopa, can be proposed to patients with hyperadrenergic features, including hyperhidrosis and tachycardia.

Beyond these drugs, immunological therapy with intravenous immunoglobulins [IVIG] has been proposed for compassionate use in a patient with autoimmune features

Diagnosis protocol: Figure 2 in the paper shows a diagnosis algorithm to differentiate between PASC (long COVID) and other conditions that may resemble it. Some of the tests include:

  • CRP (C-reactive protein) / PCT (procalcitonin) - markers of systemic inflammation and bacterial infection
  • NT-proBNP - High levels can mean your heart isn’t pumping as much blood as your body needs → heart failure
  • TSH - thyroid stimulating hormone levels indicate a healthy/unhealthy thyroid
  • Morning cortisol - cortisol level may show problems with the adrenal glands or pituitary gland
  • Holter ECG - This portable device tracks the patient’s heart rhythm over 1 or 2 days.
  • 24-hour ambulatory blood pressure monitoring - portable device that tracks blood pressure.
  • Exercise testing
  • Valsalva maneuver - a breathing method that may slow your heart when it’s beating too fast.
  • Auto-antibody testing if known or suspected autoimmune condition
  • Serum (blood levels of) histamine and tryptase testing if MCAS suspected. MCAS symptoms include flushing, headache, GI symptoms.