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Multiple System Atrophy – Orthostatic Hypotension — SCE Neurology MCQ

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HardMovement DisordersMultiple System Atrophy – Orthostatic HypotensionSCE Neurology

A patient with multiple-system atrophy has symptomatic orthostatic hypotension despite fluid, salt, compression and medication review. Supine blood pressure is acceptable. Which pharmacological step is most appropriate?

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Correct answer: C — Consider midodrine with specialist monitoring for supine hypertension and urinary adverse effects

The best answer is “Consider midodrine with specialist monitoring for supine hypertension and urinary adverse effects”. Midodrine is an alpha-agonist option after non-pharmacological measures; its benefit must be balanced against supine hypertension and urinary retention. “Start a long-acting nitrate to reduce standing venous pooling” remains a plausible alternative in a different presentation, but it does not fit the decisive finding or management threshold here. “Use propranolol to increase peripheral vascular resistance during standing” remains a plausible alternative in a different presentation, but it does not fit the decisive finding or management threshold here. “Begin a loop diuretic to reduce autonomic blood-pressure variability” remains a plausible alternative in a different presentation, but it does not fit the decisive finding or management threshold here. “Add levodopa specifically to restore baroreflex vasoconstriction” remains a plausible alternative in a different presentation, but it does not fit the decisive finding or management threshold here.

Reference: NICE NG71 Parkinson’s disease recommendations: https://www.nice.org.uk/guidance/ng71/chapter/recommendations