Synergistic effect of norepinephrine transporter blockade and α-2 antagonism on blood pressure in autonomic failure.
Patients with autonomic failure have disabling orthostatic hypotension because of impaired sympathetic activity. Norepinephrine transporter blockade with atomoxetine raises blood pressure in autonomic failure by increasing synaptic norepinephrine concentrations in postganglionic sympathetic neurons. This effect requires tonic release of norepinephrine, which is decreased in patients with low sympathetic tone. We hypothesized that increasing residual sympathetic outflow with the α-2 antagonist yohimbine would potentiate the pressor effect of norepinephrine transporter blockade with atomoxetine and improve orthostatic tolerance in peripheral autonomic failure. Seventeen patients received a single oral dose of either placebo, yohimbine 5.4 mg or atomoxetine 18.0 mg, and the combination yohimbine and atomoxetine in a single blind, crossover study. Blood pressure was assessed while patients were seated and standing for ≤10 minutes before and 1 hour postdrug. Neither yohimbine nor atomoxetine significantly increased seated systolic blood pressure or orthostatic tolerance compared with placebo. The combination, however, significantly increased seated systolic blood pressure and orthostatic tolerance (P<0.001 and P=0.016, respectively) in a synergistic manner. The maximal increase in seated systolic blood pressure seen with the combination was 31±33 mm Hg at 60 minutes postdrug. Only the combination showed a significant improvement in orthostatic symptoms. In conclusion, the combination of yohimbine and atomoxetine had a synergistic effect on blood pressure and orthostatic tolerance in peripheral autonomic failure, which may be explained by an increased release of norepinephrine in peripheral sympathetic neurons by α-2 antagonism combined with a reduced norepinephrine clearance by norepinephrine transporter blockade. Safety studies are required to address the clinical usefulness of this pharmacological approach.
Vanderbilt Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA.
Luis E
LE
Okamoto
Cyndya
C
Shibao
Alfredo
A
Gamboa
Leena
L
Choi
André
A
Diedrich
Satish R
SR
Raj
Bonnie K
BK
Black
David
D
Robertson
Italo
I
Biaggioni
D018759:Adrenergic Uptake Inhibitors / Q000008:administration & dosage*; D058669:Adrenergic alpha-2 Receptor Antagonists / Q000008:administration & dosage*; D000368:Aged; D000069445:Atomoxetine Hydrochloride; D001794:Blood Pressure / Q000187:drug effects*; D018592:Cross-Over Studies; D004305:Dose-Response Relationship, Drug; D004357:Drug Synergism; D004359:Drug Therapy, Combination; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D050484:Norepinephrine Plasma Membrane Transport Proteins / Q000037:antagonists & inhibitors* / Q000378:metabolism; D004856:Postural Balance / Q000187:drug effects; D011437:Propylamines / Q000008:administration & dosage*; D011446:Prospective Studies; D012791:Shy-Drager Syndrome / Q000188:drug therapy* / Q000378:metabolism / Q000503:physiopathology; D016037:Single-Blind Method; D016896:Treatment Outcome; D015016:Yohimbine / Q000008:administration & dosage*
D018759:Adrenergic Uptake Inhibitors; D058669:Adrenergic alpha-2 Receptor Antagonists; D050484:Norepinephrine Plasma Membrane Transport Proteins; D011437:Propylamines; D015016:Yohimbine; D000069445:Atomoxetine Hydrochloride