Alpha blockers
Bunazosin, doxazosin, indoramine, naftopidil, phenoxybenzamine, phentolamine, terazosin, parazosin, tolazoline, urapidil.
Centrally acting antihypertensive drugs (alpha agents):
Apraclonidine, brimonidine, clonidine, guanabenz, guanfacine, methyldopa, moxonidine, rilmenidine.
Beta-blockers
ACE inhibitors
Calcium channel blockers
Diuretics
Osmotic diuretics
Potassium sparing diuretics
Thiazides
Nitrates
Sympathomimetics
Vasodilators
Orthostatic hypotension.
Caplyta_pi.pdf lumateperone
INFORMATION FOR THE PATIENT
WHAT DO THE AUTONOMIC LABORATORY DO?
Nerves in the brain, spinal cord, and peripheral nerve comprise 3 types of fibers: Motor, sensory, and autonomic. Motor fibers go to control voluntary muscles and are responsible for some volition (willed) motor acts such as contracting a muscle. Sensory fibers are connected to receptors and can transmit information on whether the skin is warm or cold, whether it is being touched or hurt etc. The third category of fibers are Autonomic and control autonomic or more appropriately automatic functions such as heart rate, sweating, the state of constriction (narrowing) or relaxation (widening) of small blood vessels. If the last function is abnormal, blood flow to the hands and/or feet may be abnormal and the extremity may be unusually cold or may have an unusual color. If the abnormality is more severe, symptoms such as lightheadedness on standing, may develop. These same nerve fibers control heart rate, sexual, bladder and bowel function, so that how well these fibers work are clearly important.
The autonomic tests are done in a orderly sequence.
1. QSART (quantitative sudomotor axon reflex sweat test):
A small number of capsules, usually 4, are secured on the patient's arm and leg, preferably left side. The capsule has especially arranged compartment so that some autonomic fibers can be stimulated in one skin area while the resulting sweat output is recorded from another area. If the nerve fibers are not working, as in some neuropathies, then the sweat response will not occur or the response may be less than normal. During the stimulation a mild stinging sensation is felt on the 4 areas where the capsule is placed. After removal of the capsules and area of mild redness (neurogenic flare) of the skin may be noticeable and this will clear up.
2. Heart rate and blood pressure recordings:
To further test if the autonomic nerve fibers are working normally, heart rate and blood pressure is recorded with the patient lying quietly and comfortably. The patient may be asked to do certain maneuvers such as taking deep breaths (response to deep breathing) or to blow into a bugle (Valsalva maneuver). Lastly, the patient is tilted upright on a tilt table. Skilled personnel will be present to monitor and instruct the patient during the duration of test.
INSTURCTIONS TO PATIENTS TO BE FOLLOWED
Preparation before autonomic testing is aimed at factors that may confound testing results. These include the use of certain medications). Please provide a complete list of medications and OTC you are taking to determine when they should be held prior to testing. Please check with your prescribing physician if it safe for you to be off these medications for any length of time. The referring provider should carefully weigh the potential risk of pausing these medications against the value of uncompromised test results. Ideally, all medication with at least theoretical impact on autonomic testing should be held for at least 4 half-lives. As this is often impractical and logistically difficult, the following guidelines have proven helpful in providing of reasonable compromise:
In order to obtain the most reliable information from autonomic tests, the following instructions should be followed:
Recommendations:
Alcohol, excessive exercise must be avoided 24 hours prior to study.
Coffee and other caffeinated beverages: Avoid 12 hours prior to study.
No tobacco products 8 hours prior. The antecedent meal should be a light breakfast or lunch without coffee or tea or other caffeinated beverages.
No constrictive clothing, e.g. Jobst stockings, binders, corsets on day of study.
You should have been indoor for half an hour prior to the test.
You should not be distressed (emotionally or in pain) at the time of the test. You should be comfortable (bladder recently emptied and pain-free).
The room should be warm and quiet. Please turn off cell-phones for the duration of the test.
No cold/allergy medicine 24 hours prior as it inhibits sweating.
No lotions, oils, creams as it clog the sweat pores.
Do not shave legs day of test. Avoid nicks and cuts.
Key medications that should be held for at least 48 hours before autonomic reflex screen (if safe to do so) include:
Do not take anticholinergic drugs (check with your physician) for at least 48 hours, and ideally 4 days, prior to your test. In general, anticholinergic medications have the side effects of making your mouth feel dry.
Some Drugs with potent anticholinergic effects: Amitriptyline, Topiramate, Zonisamide, Oxybutynin, and Bupropion.
Some Drugs with moderate/modest anticholinergic effects: Clonidine, Nortriptyline, Chlorpromazine, and Thioridazine
Medication with partial anticholinergic properties (atropine, scopolamine, glycopyrrolate, oxybutynin, tolterodine, trospium).
SSRIs and SNRIs (fluoxetine, paroxetine, venlafaxine).
Antiseizure medications (topiramate, zonisamide)
Antihistamines (diphenhydramine, promethazine)
Alpha-2 agonists (clonidine)
Antipsychotic/antiemetics (chlorpromazine, clozapine)
Muscle relaxants (cyclobenzaprine, tizanidine)
Fludrocortisone
Additional Key medication that should be held the day of an autonomic reflex screen (if safe to do so):
Alpha blockers (doxazosin, prazosin, terazosin), beta-blockers (metoprolol, propranolol, bisoprolol), vasodilators including CCB, hydralazine, and nitrates; and potent diuretics.
ACE-I/ARB: lisinopril, losartan.
Opioids (fentanyl, morphine, oxycodone, hydrocodone).
Pyridostigmine, droxidopa, midodrine
Stop antidepressants (SSRIs and Tricyclics), trazodone and amantadine 7 days prior to study if able.
Stop stimulants, e.g. Ritalin/methylphenidate, Concerta, and Adderall/dextroamphetamine/amphetamine, phenterimine 3 days prior if able.
Stop antihistamines, e.g. Claritin/loratidine, Antivert/meclizine, Zyrtec/cetirizine 2 days prior if able.
Stop bladder medications, e.g. Detrol/tolterodine, Flomax/tamsulosin and Ditropan/oxybutynin 2 days prior if able.
Stop muscle relaxers, e.g. Flexeril/cyclobenzaprine 7 days prior if able.
Stop dopamine agonists, e.g. Mirapex/pramipexole 7 days prior to the study if able.
Stop calcium channel blockers, e.g. Norvasc/amlodipine 4 days prior if able.
Stop beta blockers, e.g. Lopressor/metoprolol, Tenormin/atenolol 5 days prior if able.
Stop Florinef/fludrocortisone 5 days prior if able.
Anticholinergics, and diuretics should be stopped 48 hours and preferably 4 days.
β-blockers and α-antagonist/agonists should be stopped 5 half-lives.
Biggest effect is on sudomotor function (M3 antagonists) so most of presentation is on anticholinergic effects of medications
Some Drugs with potent anticholinergic (M3) effects on secretions (sweating): Amitriptyline, Topiramate, Zonisamide, Oxybutynin, and Bupropion.
Some Drugs with moderate/modest anticholinergic (M3) effects: Clonidine, Nortriptyline, Chlorpromazine, and Thioridazine
Some Drugs with anti-cholnergic properties:
Antiparkinsonian: Benztropine, Biperiden, Procyclidine, Trihexyphenidyl.
Antispasmodics/Miscellaneous GI or GU Agents: Anisotropine, Belladonna Alkaloids, Clidinium, Dicyclomine, Flavoxate, Glycopyrrolate, Hyoscyamine, Isopropamide, Mepenzolate, Methantheline, Methscopolamine, Oxybutynin, Propantheline.
Mydriatics/Cycloplegics
Atropine
Cyclopentolate
Homatropine
Scopolamine
Tropicamide
Mydriacyl
Skeletal Muscle Relaxants
Cyclobenzaprine
Flexeril
Orphenadrine
Norflex
Antidiarrheals
Diphenoxylate/Atropine
Lomotil
Tincture of Belladonna
Loperamide
Antiemetics/Antivertigo
Cyclizine
Marezine
Dimenhydrinate
Dramamine
Meclizine
Prochlorperazine
Promethazine
Scopolamine
Trimethobenzamide
Antiarrhythmics (Class 1A)
Disopyramide
Procainamide
Quinidine
Antidepressants (SSRIs)
Fluoxetine
Fluvoxamine
Paroxetine
Sertraline
Amitriptyline
Clomipramine
Desipramine
Doxepin
Imipramine
Nortriptyline
Protriptyline
Trimipramine
Buproprion
Maprotiline
Nefazodone
Trazodone
Venlafaxine
Antihistamines/Antipruritics
Azatadine
Astemizole
Brompheniramine
Carbinoxamine
Cetirizine
Chlorpheniramine
Clemastine
Cyproheptadine
Dexchlorpheniramine
Diphenhydramine
Hydroxyzine
Loratadine
Methdilazine
Terfenadine
Trimeprazine
Tripelennamine
Triprolidine
Neuroleptics
Chlorpromazine
Thorazine
Clozapine
Fluphenazine
Haloperidol
Loxapine
Mesoridazine
Molindone
Perphenazine
Pimozide
Risperidone
Thioridazine
Thiothixene
Trifluoperazine
Adrenergic function, usually tested as head-up tilt and beat-to-beat BP responses to the Valsalva maneuver can be affected by a number of drugs especially A1 adrenergic antagonists or arteriolar smooth muscle relaxants.
2.
Anti-adrenergic drugs usually do not cause orthostatic hypotension in most patients, although they can have some effect on adrenergic indices.
3.
However, anti-adrenergic drugs can have a cogent effect on patient with adrenergic failure, aggravating orthostatic hypotension.
4.
They can cause orthostatic hypotension in the elderly, who often have mild or subtle adrenergic impairment.
5.
Drugs that have a potent effect on adrenergic function are mainly those prescribed to treat hypertension or urinary dysfunction or erectile dysfunction.
SOME DRUGS THAT AFFECT AUTONOMIC ADRENERGICFUNCTION
Some Drugs with potent adrenolytic effects:
Methyldopa
Adrenolytic
Aldomet
Prazosin
α-adrenergic blocker
Minipress
Tamsulosin
α-adrenergic blocker
Flowmax
Some Drugs with moderate adrenolytic effects:
Isocarboxazid
MAOI
Marplan
Phenelzine
MAOI
Nardil
Amitriptyline
Antidepressant
Elavil
Levodopa
Antiparkinsonian
Sinemet
Levodopa/carbidopa/entacapone
Stalevo
Chlorpromazine
Phenothiazine
Thioridazine
Phenothiazine
Insulin
Cardiovagal function, usually tested as HRDB can be affected by a number of drugs that are M2 antagonists.
2.
There is a commonly held misconception that drugs that slow heart rate (beta blockers) inhibit HRDB. They do not.
3.
Beta blockers do not directly reduced HRDB, but can sometimes reduce Valsalva ratio, by blunting BP overshoot.
4.
There are reports in the literature that SSRIs, nicotine and opioids cause a moderate or mild inhibition of HRDB.
5.
Drugs that have a potent effect on HRDB are non-selective muscarinic antagonists (M2/M3) such as atropine, glycopyrrolate, scopolamine and tropicamide.
6.
Diphenhydramine and oxybutynin (mainly M1/M3/M4) have a mild/moderate suppressant effect.
You have been scheduled for Autonomic Testing at Henry Ford Hospital, in Detroit.
The address is:
Grand Blvd, Detroit, MI 48202
The Autonomics lab is located on A5. To reach A5, please take the elevators in the main lobby, located directly behind the information desk. When you step off the elevator on the fifth floor, turn to your left, and you will see the Clinical Neurophysiology Department waiting room. Check in at the front desk, and the technician will come and take you to the back for your testing. Please arrive early for your testing. You should have been indoor for half an hour prior to the test. The test can be 1½ to 2 hours long. If you need to reach the department, the phone number is 313-916-2555.
WHAT DO THE AUTONOMIC LABORATORY DO?
Nerves in the brain, spinal cord, and peripheral nerve comprise 3 types of fibers: Motor, sensory, and autonomic. Motor fibers go to control voluntary muscles and are responsible for some volition (willed) motor acts such as contracting a muscle. Sensory fibers are connected to receptors and can transmit information on whether the skin is warm or cold, whether it is being touched or hurt etc. The third category of fibers are Autonomic and control autonomic or more appropriately automatic functions such as heart rate, sweating, the state of constriction (narrowing) or relaxation (widening) of small blood vessels. If the last function is abnormal, blood flow to the hands and/or feet may be abnormal and the extremity may be unusually cold or may have an unusual color. If the abnormality is more severe, symptoms such as lightheadedness on standing, may develop. These same nerve fibers control heart rate, sexual, bladder and bowel function, so that how well these fibers work are clearly important.
The autonomic tests are done in an orderly sequence.
1. QSART (quantitative sudomotor axon reflex sweat test):
Four capsules are secured on your arm and leg, preferably left side. The capsule has especially arranged compartment so that some autonomic fibers can be stimulated in one skin area while the resulting sweat output is recorded from another area. If the nerve fibers are not working, as in some neuropathies, then the sweat response will not occur or the response may be less than normal. During the stimulation a mild stinging sensation is felt on the four areas where the capsules is placed. After removal of the capsules an area of mild redness of the skin (like a mild hickey) may be noticeable and this will clear up.
2. Heart rate and blood pressure recordings:
To further test if the autonomic nerve fibers are working normally, heart rate and blood pressure is recorded with the patient lying quietly and comfortably. The patient may be asked to do certain maneuvers such as taking deep breaths (response to deep breathing) or to blow into a bugle (Valsalva maneuver). Lastly, the patient is secured with straps and tilted upright on a tilt table. Skilled personnel will be present to monitor and instruct the patient during the duration of all the tests.
INSTURCTIONS TO PATIENTS TO BE FOLLOWED
Please shower the night before testing and do not use any body lotion, creams, oils, or powders below the neck.
Do not wear tight clothing.
Please make sure your medication list is current.
Ideally, you will change into a gown.
The technician may shave small areas on your forearm and leg for better securing recording devices. These recording areas will be cleaned with acetone, alcohol, and water, prior to the attachment of devices.
Preparation before autonomic testing is aimed at reducing factors that may influence testing results. These include the use of certain medications. Please provide a complete list of medications (prescription and over the counter, supplements, etc.) you are taking to prior to scheduling an appointment for the autonomic testing. This is important for us to determine when they should be held prior to testing. Please check with your prescribing physician if it safe for you to be off these medications for any length of time. The referring provider should carefully weigh the potential risk of pausing these medications against the value of uncompromised test results. Ideally, all medication with at least theoretical impact on autonomic testing should be held for at least 4 half-lives. As this is often impractical and logistically difficult, the following guidelines have proven helpful in providing of reasonable compromise:
Recommendations:
Alcohol, excessive exercise must be avoided 24 hours prior to study.
Coffee and other caffeinated beverages, and nicotine: Avoid 8 hours prior to study.
No food: 3 hours prior to study.
The antecedent meal should be a light breakfast or lunch without coffee or tea or other caffeinated beverages.
No constrictive clothing, e.g. Jobst stockings, binders, corsets on day of study.
You should have been indoor for half an hour prior to the test.
You should not be distressed (emotionally or in pain) at the time of the test. You should be comfortable (bladder recently emptied and pain-free).
The room should be warm and quiet. Please turn off cell-phones for the duration of the test.
Key medications that should be held for at least 48 hours before autonomic reflex screen (if safe to do so) include:
Do not take anticholinergic drugs (check with your physician) for at least 48 hours, and ideally 4 days, prior to your test. In general, anticholinergic medications have the side effects of making your mouth feel dry.
Some Drugs with potent anticholinergic effects: Amitriptyline, Topiramate, Zonisamide, Oxybutynin, and Bupropion.
Some Drugs with moderate/modest anticholinergic effects: Clonidine, Nortriptyline, Chlorpromazine, and Thioridazine
Medication with partial anticholinergic properties (atropine, scopolamine, glycopyrrolate, oxybutynin, tolterodine, trospium).
SSRIs and SNRIs (fluoxetine, paroxetine, venlafaxine).
Antiseizure medications (topiramate, zonisamide)
Antihistamines (diphenhydramine, promethazine)
Alpha-2 agonists (clonidine)
Antipsychotic/antiemetics (chlorpromazine, clozapine)
Muscle relaxants (cyclobenzaprine, tizanidine)
Fludrocortisone
Additional Key medication that should be held the day of an autonomic reflex screen (if safe to do so):
Alpha blockers (doxazosin, prazosin, terazosin), beta-blockers (metoprolol, propranolol, bisoprolol), vasodilators including CCB, hydralazine, and nitrates; and potent diuretics.
ACE-I/ARB: lisinopril, losartan.
Opioids (fentanyl, morphine, oxycodone, hydrocodone).
Pyridostigmine, droxidopa, midodrine
Marijuana (in any form) should not be used for at least 3 days prior to test.
Amitriptyline (Elavil): Stop 7 days prior to the ARS.
Hydrochlorothiazide: Stop the day of ARS
Nitroglycerin: Stop the date of ARS
Trazodone: Stop 7 days prior to the ARS
Isosorbide mononitrate (Imdur): Stop 24 hours prior to the ARS
Liao Y, Qi JG, Yan H, Zhang QY, Ji TY, Chang XZ, Yang HP, Jin HF, Du JB. Comorbidity of chronic fatigue syndrome, postural tachycardia syndrome, and narcolepsy with 5,10-methylenetetrahydrofolate reductase (MTHFR) mutation in an adolescent: a case report. Chin Med J (Engl). 2021 Mar 25;134(12):1495-1497. doi: 10.1097/CM9.0000000000001387. PMID: 33788782; PMCID: PMC8213257.
https://pmc.ncbi.nlm.nih.gov/articles/PMC8213257/
Adult ADHD Medications and Their Cardiovascular Implications - PMC