# Treatments for multiple system atrophy
There is no medication for multiple system atrophy (MSA) that stops or reverses the underlying disease. Treatment therefore focuses on relieving symptoms and maintaining quality of life. Which treatments are used depends on which symptoms are most prominent and which stage of the disease the person is in.
Movement disorders (parkinsonism and cerebellar disorders)
Levodopa
ProveniIncluded in official guidelines, or approved by EMA or FDA
Levodopa is a precursor of dopamine (a brain substance that is lacking in parkinsonian symptoms). It is converted to dopamine in the brain and can reduce tremor, rigidity and slowness.
In MSA, levodopa often works less well than in Parkinson's disease. Only some patients respond to it. Many patients eventually experience no benefit, particularly as the disease progresses.
Known side effects include nausea, headache, dizziness and sometimes involuntary movements. These side effects can be reduced by taking other medication at the same time.
Other dopaminergic medications (dopamine agonists)
ProveniIncluded in official guidelines, or approved by EMA or FDA
Medications such as ropinirole and pramipexole mimic dopamine and can help with parkinsonian symptoms.
They are sometimes used as a first choice or in combination with levodopa. The effect is often limited in MSA.
Possible side effects include dizziness, drowsiness, swelling of feet and legs, and sometimes impulse control disorders (urge to gamble, compulsive shopping).
Amantadine
ProveniIncluded in official guidelines, or approved by EMA or FDA
Amantadine works in multiple ways in the brain and can help with rigidity and slowness.
It is sometimes used as a supplement to levodopa. The effect is usually modest.
Possible side effects include confusion, insomnia, swollen feet and sepsis.
Beta-blockers and other anti-tremor medications (propranolol, primidone)
ProveniIncluded in official guidelines, or approved by EMA or FDA
These medications can reduce tremor, especially if it is prominent.
They are not specifically prescribed for MSA, but can be useful if tremor is a major problem.
Propranolol can cause fatigue and low blood pressure. Primidone can cause drowsiness and dizziness.
Brain stimulation (deep brain stimulation)
UnproveniNo scientific evidence that it works
Deep brain stimulation (DBS) — implanting electrodes in certain parts of the brain — works well in Parkinson's disease. In MSA, the effect is poor and unreliable, because the disease affects multiple brain regions.
This is therefore not recommended for MSA patients.
Autonomic nervous system (blood pressure, perspiration, bladder)
Orthostasis (low blood pressure when standing up)
ProveniIncluded in official guidelines, or approved by EMA or FDA
Non-pharmacological:
- Drink sufficient fluid
- Salt in food (promotes fluid retention)
- Elastic stockings (prevent blood from pooling in legs)
- Foot and leg tension exercises before standing up
These measures form the basis of treatment.
Medications:
Agents such as midodrine (constricts blood vessels) and fludrocortisone (retains fluid) are prescribed to raise blood pressure. Recent studies compare the effectiveness of midodrine with other aids such as abdominal binders.
Possible side effects of midodrine include headache, tingling and insomnia. Fludrocortisone can cause fluid retention and potassium deficiencies.
Persistent high blood pressure (hypertension)
ProveniIncluded in official guidelines, or approved by EMA or FDA
Paradoxically, MSA patients may have low blood pressure during the day but high blood pressure at night.
Taking a low dose of blood pressure lowering medication in the evening (usually a calcium antagonist) is sometimes used to prevent nocturnal hypertension, without further lowering the already problematic daytime blood pressure.
Excessive sweating
ProveniIncluded in official guidelines, or approved by EMA or FDA
Non-pharmacological:
- Wear light clothing
- Adjust fluid intake
- Keep bedroom cool
Medications:
Anticholinergic medications (such as certain antidepressants) can reduce excessive sweating. Their effectiveness varies.
Possible side effects are dry mouth, constipation and drowsiness.
Bladder and bowel problems
ProveniIncluded in official guidelines, or approved by EMA or FDA
For urge incontinence (sudden urge) anticholinergic medications (oxybutynin, solifenacine) are used.
In case of retention (insufficient emptying) intermittent catheterization or, rarely, permanent catheterization may be needed.
For constipation osmotic laxatives (such as macrogol) and bulk-forming agents are used. This is supportive care.
Side effects of anticholinergic medications: dry mouth, blurred vision, constipation.
Symptoms of the cerebellum (coordination problems)
Physical rehabilitation and speech therapy
ProveniIncluded in official guidelines, or approved by EMA or FDA
Physical therapy aimed at balance, coordination and gait helps reduce symptoms and decrease fall risk.
Speech therapy helps with speech and swallowing technique.
These are supportive, non-pharmacological treatments with no direct side effects, but require effort.
Medication support
There is no medication that specifically counteracts cerebellar symptoms. Sometimes medications such as buspirone or isoniazid are investigated, but evidence is weak.
Swallowing and breathing problems
Speech therapy and swallowing technique
ProveniIncluded in official guidelines, or approved by EMA or FDA
Adjustments in eating and drinking technique (eating slower, certain consistencies) prevent choking.
This is an important part of care in later stages.
Tube feeding
ProveniIncluded in official guidelines, or approved by EMA or FDA
With severe swallowing difficulties tube feeding through a gastric tube (PEG tube) may be necessary.
This facilitates feeding and reduces choking, but is an intervention with psychological and practical implications.
Mechanical ventilation
ProveniIncluded in official guidelines, or approved by EMA or FDA
In later stages breathing problems (sleep apnea, shallow breathing) may occur. Non-invasive ventilation (CPAP or BiPAP) can help at night.
Studies suggest that nutritional status and fluid intake influence whether someone can remain without mechanical ventilation.
Experimental and investigational treatment
Anti-α-synuclein therapies
ExperimentaliOngoing in study setting, outcome still unknown
Recent studies focus on medications that specifically target the protein aggregate α-synuclein (monoclonal antibodies and similar).
These are still in clinical trial phase. Laboratory studies show promising effects, but use in patients is still limited.
This is an area with much research activity, also beyond MSA.
Neuroprotective approaches
ResearchediPositive results in clinical studies, not yet standard treatment
Medications that inhibit inflammatory processes in the brain or strengthen certain cellular safety mechanisms are being investigated.
This includes agents specifically targeting mitochondrial function, oxidative stress and neuroinflammation. Multiple studies are ongoing.
These are not yet in standard treatment.
Biomarkers for prognosis and disease course
ResearchediPositive results in clinical studies, not yet standard treatment
Recent research shows that certain blood markers and MRI patterns (iron deposits, atrophy of certain brain regions) are predictive of disease progression rate.
This helps to better classify patients into groups (rapid versus slow progression), which may be relevant for research and treatment planning.
This is not a treatment itself, but supports diagnosis and prognosis.
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_This information never replaces a doctor's judgment. Always discuss your situation with your own healthcare provider._