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My Treatment Approach to Multiple System Atrophy

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Dr. Elizabeth Coon, an Assistant Professor of Neurology at Mayo Clinic in Rochester, MN, reviews her article coauthored with Dr. J. Eric Ahlskog appearing in the March 2021 issue of Mayo Clinic Proceedings, where she describes the symptoms, diagnosis, and treatment options available for the rare but devasting condition of multiple system atrophy. She notes many pharmacologic and non-pharmacologic approaches used to treat autonomic and movement symptoms as well as the importance of partnering with subspecialists and local care providers to improve quality of life of patients, their caregivers and families. Available at:

We know that the diagnosis of multiple system atrophy can be difficult to make and often occurs at a tertiary care center yet when patients go home their primary care providers are on the front line of their care so we sought to bridge the gap between tertiary care providers and patients local care providers in caring for patients with multiple system atrophy

To try and ensure that they can have the best quality of life possible hello i’m dr elizabeth kuhn a neurologist at mayo clinic in rochester minnesota specializing in movement and autonomic disorders thank you for the opportunity to talk about our recent paper my treatment approach in multiple system atrophy published in mayo clinic proceedings i’m grateful to

Have the opportunity to work with my movement disorders mentor dr eric alstogg on this work dr alstock has extensive experience caring for patients with multiple system atrophy first i’m going to talk about multiple system atrophy then i’m going to talk about different treatment approaches that we have found to be helpful and then lastly i’m going to talk about

Multi-disciplinary care models and how this can also be done through collaborating with primary care physicians now multiple system atrophy is a neurodegenerative disorder it progresses at varying paces and is characterized by both motor and autonomic failure the motor impairment is characterized by parkinsonism which looks like parkinson’s disease but typically

Does not respond as well to the classic medications used to treat it or can be predominantly cerebellar cerebellar ataxia termed msac this form has much more imbalance and coordination and affects fine motor as well as gate walking difficulties and can lead to falls in terms of the autonomic failure this classically presents with orthostatic hypotension which is

A drop in blood pressure upon standing the blood pressure can get so low so that patients can have syncopal episodes and our risk for injury associated with those also we know that with that orthostatic hypotension though patients may have supine hypertension meaning when they’re lying flat their blood pressure is too high so this can create a unique treatment

Challenges genital urinary failure is often commonly seen in multiple system atrophy and this can present with sexual dysfunction in men or women and then urinary frequency urgency and incontinence constipation can be problematic as well as another autonomic failure anhidrosis or a reduction in sweating and difficulty with thermoregulation in addition to the

Autonomic and movement components to multiple system atrophy we can see sleep disorders frequently dream enactment behavior characteristic of rem sleep behavior disorder is problematic for patients and strider is a classic finding as well this is impaired mobility of the vocal cords that can lead to a type sound heard by patients bed partners and sometimes

During the day in addition to the motor autonomic and sleep dysfunction we can see other issues occurring in patients with multiple system attributes as well this includes depression anxiety and about half of msa patients also demonstrate pain which can take a variety of different courses with this complex set of symptoms often the treatment can be very

Difficult or complex but there are some simple things that we can do to try and optimize care for patients with msa and really get that best quality of life from the motor standpoint for parkinsonism we tend to recommend carbidopa levodopa replacing dopamine this can help with patients mobility uh and help with some of the stiffness and sometimes pain that can

Go along with multiple system atrophy we do watch out for excessive dyskinesias or extra movements that can occur with treatment with levodopa and even though the response isn’t as good as what we tend to see in parkinson’s disease patients often can have some benefit meaning it’s an important uh part of the treatment in these patients now cerebellar ataxia

Really doesn’t have a pharmacologic treatment but that’s where partnering with physical therapy can be really helpful to maintain mobility and really trying to reduce fall risk as much as possible now the autonomic features in multiple system atrophy uh can take a lot of different courses as for treatment for orthostatic hypotension in the paper we outline

A lot of non-pharmacologic measures so increasing fluid status and specifically doing something called cold water fluid boluses we also talk about pharmacologic ways to do this volume expansion and flu draw cortisone is one medication that can be helpful a mitodryn is a vasoconstrictive agent that can be helpful in patients with multiple system atrophy now

Mitogen can also lead to that supine hypertension so care needs to be taken so that patients do not lie flat for four hours after taking my dread so non-pharmacologically having the head of the bed elevated can be helpful and having patients check blood pressures while lying flat before bedtime is also helpful to guide our management we tend to use this

Multi-disciplinary care model because you can see with these different symptom manifestations and all the necessary treatments a lot of different providers are often involved in their care including physical medicine and rehabilitation physical therapy occupational therapy speech therapy sleep medicine urology and sometimes gastroenterology as well we have

Found palliative medicine can be very helpful in caring for these patients both early on after diagnosis throughout the disease and as we transition towards more end of life cares now we have put together an msa multi-disciplinary clinic at rochester and have really partnered with palliative medicine as well as these other subspecialties what we hope to see

In a more nationwide nationwide basis is multiple system atrophies centers of excellence so following in other neurodegenerative disorder care models as well and with this we really seek to care for both the patient to improve the quality of life but also try and support the caregiver and families as they are going through this disease as well we hope you

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My Treatment Approach to Multiple System Atrophy By Mayo Proceedings