Pavic Nicholas Vlado, Zhang Shane, Maloof Alexander George, Goh Rudy, Kovoor Joshua, Kovoor Pramesh, Postuma Ron, Lau Dennis, Edwards Suzanne, Bacchi Stephen
Medicine, Flinders University College of Medicine and Public Health, Adelaide, South Australia, Australia
Medicine, Royal North Shore Hospital, St Leonards, New South Wales, Australia.
Open Heart. 2025 Mar 25;12(1):e003106. doi: 10.1136/openhrt-2024-003106.
Current pharmacological approaches for the treatment of orthostatic hypotension (OH) may detrimentally affect supine blood pressure (BP). This side effect is often unacceptable and limits the utility of medical management. Pyridostigmine has been proposed as a potential treatment alternative which may improve OH without worsening supine hypertension. This systematic review and meta-analysis aimed to evaluate the currently available data regarding the use of pyridostigmine in the treatment of all-cause OH.
A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed, EMBASE, Cochrane and SCOPUS were searched for publications until 4 June 2024. A random-effects model was used for meta-analysis.
The search returned 715 results, of which 6 randomised controlled trials met the inclusion criteria. Several studies reported a statistically significant improvement in orthostatic BP following pyridostigmine administration. Two studies found that pyridostigmine had no effect on standing BP among patients with severe autonomic failure. One study suggested that combination therapy with atomoxetine may elicit a synergistic effect. In most studies, pyridostigmine had no significant effect on supine BP. Adverse effects were minimal across the included studies. The pooled results from the meta-analysis showed that while pyridostigmine alone resulted in lower systolic and diastolic orthostatic drop, neither result was statistically significant. However, when pyridostigmine is combined with midodrine, this demonstrated a significant improvement in systolic orthostatic drop.
Pyridostigmine may be useful in the management of OH, particularly in patients with supine hypertension. The standing BP response to pyridostigmine may be greater in patients who have a relatively preserved baroreflex function and sympathetic reserve.
CRD42024555402.
目前用于治疗体位性低血压（OH）的药物治疗方法可能会对仰卧位血压（BP）产生不利影响。这种副作用通常是不可接受的，并且限制了药物治疗的效用。已提出吡啶斯的明作为一种潜在的治疗选择，它可能改善OH而不加重仰卧位高血压。本系统评价和荟萃分析旨在评估目前关于使用吡啶斯的明治疗全因性OH的可用数据。
根据系统评价和荟萃分析的首选报告项目指南进行系统评价。在PubMed、EMBASE、Cochrane和SCOPUS中检索截至2024年6月4日的出版物。采用随机效应模型进行荟萃分析。
检索返回715条结果，其中6项随机对照试验符合纳入标准。几项研究报告称，服用吡啶斯的明后体位性血压有统计学意义的改善。两项研究发现，吡啶斯的明对严重自主神经功能衰竭患者的站立血压没有影响。一项研究表明，与托莫西汀联合治疗可能产生协同效应。在大多数研究中，吡啶斯的明对仰卧位血压没有显著影响。纳入研究中的不良反应最小。荟萃分析的汇总结果表明，虽然单独使用吡啶斯的明可导致收缩压和舒张压体位性下降幅度降低，但两者结果均无统计学意义。然而，当吡啶斯的明与米多君联合使用时，收缩压体位性下降有显著改善。
吡啶斯的明可能有助于OH的管理，特别是在仰卧位高血压患者中。对于压力反射功能和交感神经储备相对保留的患者，对吡啶斯的明的站立血压反应可能更大。
PROSPERO注册号：CRD42024555402。
