Making a case for domperidone in the treatment of gastrointestinal motility disorders

There are very few treatment options currently available for patients with gastrointestinal motility disorders, especially patients with gastroparesis. Domperidone, a peripheral dopamine receptor antagonist, has been successfully used for decades in the US and marketed in many countries for the treatment of gastroparesis. Its use, however, has recently become controversial owing to safety concerns, and it has never been approved for marketing by the FDA. During the 1990s, domperidone was available to US gastroenterologists under a compassionate-use program by Janssen Pharmaceutica, as the manufacturer worked towards, and fell short of, full US market approval. Medical studies, trials and case reports demonstrate the superior efficacy of domperidone when compared with placebo and other pharmaceutical therapies available. Data on the cardiac toxicity associated with oral use of domperidone fail to be convincing.

Comparison of pramipexole and amisulpride on alertness, autonomic and endocrine functions in healthy volunteers

RATIONALE

In a previous study in healthy volunteers, the anti-Parkinsonian drug pramipexole caused sedation and pupil dilatation, consistent with the stimulation of inhibitory D(2)/D(3) autoreceptors on the ventral tegmental area dopaminergic neurones. The sedation may be related to the removal of the dopaminergic excitation of the locus coeruleus (via the meso-coerulear pathway), whereas the pupil dilatation may be due to the removal of the dopaminergic excitation of the Edinger-Westphal nucleus (via a putative meso-pupillomotor pathway).

OBJECTIVES

We investigated the hypothesis that amisulpride, a D(2)/D(3) receptor antagonist, would have effects opposite to those of pramipexole on alertness, pupillary and endocrine functions.

MATERIALS AND METHODS

Pramipexole (0.5 mg), amisulpride (50 mg), and their combination were administered to 16 healthy males in a balanced, cross-over, double-blind design. Tests included measures of alertness (Pupillographic Sleepiness Test, critical flicker fusion frequency, visual analogue scales), pupillary functions (resting pupil diameter, light and darkness reflex responses), non-pupillary autonomic functions (heart rate, blood pressure, salivation, core temperature), and endocrine functions [blood concentrations of prolactin, growth hormone (GH) and thyroid stimulating hormone (TSH)]. Data were analysed by ANOVA.

RESULTS

Pramipexole reduced alertness and pupillary light reflex response amplitude, tended to reduce core temperature, reduced prolactin levels and increased GH levels. Amisulpride reduced pupil diameter, increased the amplitude of the light reflex response and prolactin and TSH levels.

CONCLUSIONS

The opposite effects of pramipexole and amisulpride on alertness, pupillary function and pituitary hormone levels are consistent with their interactions with inhibitory D(2)/D(3) receptors on VTA neurones and in the tuberoinfundibular system.

Behavioural effects of chronic haloperidol and risperidone treatment in rats

The therapeutic properties of typical antipsychotic drugs (APDs) such as haloperidol in schizophrenia treatment are mainly associated with their ability to block dopamine D2 receptors. This blockade is accompanied by side effects such as extrapyramidal symptoms (EPS). Atypical APDs such as risperidone have superior therapeutic efficacy possibly due to their activity at multiple receptors (in particular 5-HT2A receptors). Although the risk of EPS is significantly lower in atypical than in typical APDs, it is not negligible. To investigate and compare the behavioural profile and EPS-asssociated side effects of haloperidol and risperidone APD treatment we applied a multi-tiered, comprehensive behavioural phenotyping approach. Sprague-Dawley rats were treated chronically (28 days) with supratherapeutic EPS-inducing doses of haloperidol and risperidone using osmotic minipumps. Domains such as motor activity, exploration, memory, and anxiety were analysed together with EPS assessment ("early onset" vacuous chewing movements and catalepsy). Both APDs produced diminished motor activity and exploration, impaired working memory performances, and increased anxiety levels. These effects were more pronounced in haloperidol-treated animals. Chronic APD treatment also caused a time-course dependent elevation of EPS-like symptoms. Risperidone-treated animals showed a catalepsy-like phenotype, which differed to that of haloperidol-treated rats, indicating that processes other than the anticipated dopaminergic mechanisms are underlying this phenomenon. These EPS-related phenotypes are consistent with reported EPS-inducing D2 receptor occupancies of around 80%. Differences in the behavioural profile of haloperidol and risperidone, which were revealed by a comprehensive phenotyping strategy, are likely due to the unique receptor activation profiles of these APDs.

Development of a simplified instrument for the diagnosis and grading of akathisia in a cohort of patients receiving prochlorperazine

Akathisia is a common side-effect of dopamine receptor D2 antagonists that often remains undiagnosed. Conventional diagnostic and grading instruments are cumbersome and can be difficult to remember and to use. To facilitate the Emergency Department (ED) assessment of acute drug-induced akathisia, I sought to derive and evaluate a simplified instrument using the database compiled from three prior studies of acute drug-induced akathisia. These studies had used a conventional Long instrument in the prospective assessment of 360 adult ED patients aged 17-65 years who received intravenous prochlorperazine (10 mg) in the treatment of headache or nausea and vomiting. The Short instrument was derived from the Long instrument using the Wilcoxon z-test to identify the individual findings most strongly associated with the diagnosis of akathisia. I then retrospectively applied the Short instrument to the cohort and used pairwise analyses to compare results obtained from both instruments. Sensitivity, specificity and receiver operating characteristic curves were used to analyze the impact of instrument form on diagnostic accuracy. The Long criteria diagnosed akathisia in 118 (32.8%; 95% confidence interval [CI] 28.0%-37.9%) patients and the Short diagnosed akathisia in 120 (33.3%; 95% CI 28.5%-38.5%). When akathisia was characterized categorically as either absent or present, the Short criteria agreed with the Long in 358 cases (99.4%; 95% CI 98.0%-99.9%). Treating the diagnoses established by the Long criteria as the gold standard, the Short instrument had a sensitivity of 100.0% (95% CI 96.9%-100%) and a specificity of 99.2% (95% CI 97.0%-99.9%). Regarding the accuracy of categorizing akathisia into four severity grades, the Short scale agreed in 325 of 360 cases (90.3%; 95% CI 86.7%-93.1%) and misgraded 35 cases (9.7%; 95% CI 6.9%-13.3%), 34 of which fell within one grade of the Long scale. The Short instrument is highly accurate in diagnosing acute drug-induced akathisia, in comparison with the Long criteria, in the ED setting. The Short instrument also provides fairly accurate grading of akathisia severity. This simplified instrument should facilitate the detection and treatment of akathisia in the ED.

Periocular Inflammation After Retrobulbar Chlorpromazine (Thorazine) Injection

PURPOSE

Retrobulbar chlorpromazine injection is a relatively recently described method of pain control in nonseeing eyes. This report illustrates severe sterile inflammation as a potential complication.

METHODS

In this university-based, retrospective, small case series, we reviewed the records of 2 female patients and 1 male patient (ages, 13 to 89 years) who developed severe inflammation after retrobulbar chlorpromazine injection.

RESULTS

Three patients had development of severe periocular edema after retrobulbar chlorpromazine injection. Two had development of chemosis, limited extraocular motility, proptosis, and incomplete eyelid closure, necessitating temporary tarsorrhaphy. The third patient had development of facial edema involving the ipsilateral eyelids, forehead, and cheek. Strikingly, it extended to the contralateral face. All 3 patients denied discomfort. In each case, swelling was first noted the day after injection and progressed for 1 week. All were treated with topical lubrication and two with temporary tarsorrhaphy. Resolution occurred within 3 weeks in each case.

CONCLUSIONS

Severe periocular inflammation can result from retrobulbar chlorpromazine injection and may manifest as chemosis, proptosis, limited ocular motility, and facial swelling that may extend well beyond the eyelids. Awareness of this potential adverse reaction is important both for patient counseling before injection and subsequent treatment. Specifically, a sterile inflammatory response should be differentiated from infection to avoid inappropriate therapy.

Veralipride-induced acute coronary syndrome unmasking a non-secreting pheochromocytoma

The administration of veralipride, a centrally acting dopaminergic type 2 (DA2) receptor antagonist, can decrease hot flushes and improve bone density in post-menopausal women (1). Therefore, it entails an alternative to hormone replacement therapy (HRT) in women who have contraindications to estrogen (1). We herein describe the case of a 52-yr-old lady who presented with an acute coronary syndrome shortly after taking veralipride. Based on knowledge that DA2 receptor antagonists trigger catecholamine release (2), a pheochromocytoma was suspected and thereafter diagnosed and excised. Therefore, this is the first case reporting on veralipride unmasking a silent pheochromocytoma.

Disminución del transportador de dopamina estriatal en primeros episodios psicóticos de pacientes esquizofrénicos tratados con risperidona

Extrapyramidal symptoms and Parkinsonism (PS) are side effects commonly observed with antipsychotic treatment. However, about 24% of never-treated schizophrenic patients may suffer from PS, which contrast with that 1% observed from the general population. 123I-FP-CIT SPECT has probe useful to differentiate degenerative from non-degenerative PS, so it could be interesting using it for establishing the functional state of presynaptic dopamine neurons of these patients.

AIM

To determine the dopamine transporter binding (DAT) in a homogeneous group of first-episode schizophrenic patients.

METHODS

An open, transversal study. Thirty schizophrenic in-patients and 15 healthy subjects were recruited. Patients were treated with similar doses of risperidone and all subjects were scanned with 123I-FP-CIT. Extrapyramidal symptoms and psychopathological status was assessed by Simpson-Angus, CGI and PANSS. Semi-quantitative analyses of SPECT images were performed using ROIs placed in caudate nucleus, anterior, medium and posterior putamen and occipital cortex.

RESULTS

Whole striatum 123I-FP-CIT binding ratio was significantly lower in patients than healthy subjects (t = 2.56, p < 0.014). This was observed in whole putamen (t = 2.66, p < 0.011), anterior (t = 2.35, p < 0.023), medium (t = 2.38, p < 0.022) and posterior putamen (t = 2.09, p < 0.042). No differences were observed in caudate nucleus (t = 1.81, p = 0.076). Females obtained higher binding ratios than males (t = -3.13, p < 0.003). No correlation was observed between 123I-FP-CIT binding ratios and clinical scales.

CONCLUSION

In our series, first episode schizophrenic patients treated with risperidone have a decrease striatal DAT binding assessed with 123I-FP-CIT SPECT. This alteration could be related to their own schizophrenia disease or be secondary to the antipsychotic treatment.

Acute dystonic reaction to metoclopramide in patients carrying homozygous cytochrome P450 2D6 genetic polymorphisms

BACKGROUND

Extrapyramidal syndromes (EPS) are clinically relevant side effects of metoclopramide which are often not anticipated.

PATIENTS AND METHODS

Two patients who received metoclopramide developed an acute dystonic reaction. Symptoms disappeared after biperiden or trihexyphenidyl were given. Molecular analysis of the CYP2D6 gene was performed using a PCR-based method.

RESULTS

Both patients were homozygous for inactive CYP2D6 alleles (CYP2D6*4/*4 and CYP2D6*4/*5), which are associated with slow drug metabolism.

CONCLUSION

Metoclopramide-induced acute dystonic reactions may occur in patients carrying a CYP2D6 genetic polymorphism.

Tardive dyskinesia and essential fatty acids

Tardive dyskinesia (TD) is a movement disorder described in individuals who have been treated with anti-dopaminergic agents. The pathophysiology of this condition remains to be fully elucidated. Several mechanisms like dopaminergic supersensitivity, dysfunction of striatonigral, GABAergic neurons and disturbed balance between dopaminergic and cholinergic systems have been described. Essential fatty acids (EFAs) are important components of neuronal membrane and the EFA content of these membranes can significantly influence neuronal functioning. Lower levels of EFAs have been reported in red blood cells (RBC) and plasma of individuals with moderate to severe TD. Supplementation with EFAs (omega-3 and omega-6 and ethyl-EPA) have been tried to alleviate TD in open and double-blind clinical trials and in some animal models of TD. In addition, antioxidants (Vitamin E) and melatonin have been tried. However, smaller numbers of patients and shortened length of clinical studies make it difficult to draw any definitive conclusions. Large multi-centre studies with sound methodology of both EFAs and antioxidants are needed.

Antiemetic-related dystonic reaction unmasked by removal of a scopolamine transdermal patch

A case of a dystonic reaction is presented that occurred after the use of prochlorperazine, metoclopramide and ondansetron for the treatment of post-operative nausea and vomiting. The onset of dystonia coincided temporally with the removal of a transdermal scopolamine patch used as adjunctive antiemetic therapy. Withdrawal of concurrently administered anticholinergic medication, after recent use of antiemetic medications with dopamine receptor (D2) inhibition, can unmask a dystonic reaction. This case also suggests that transdermal scopolamine may offer an innovative therapy for the treatment of acute dystonic reactions.

Prolonged extra-pyramidal side effects after discontinuation of haloperidol as an antiemetic

We describe a case of prolonged extra-pyramidal side effects after discontinuation of haloperidol as an antiemetic.

Drug Insight: from disturbed motility to disordered movement—a review of the clinical benefits and medicolegal risks of metoclopramide

Metoclopramide, the only drug approved by the FDA for treatment of diabetic gastroparesis, but used off-label for a variety of other gastrointestinal indications, has many potentially troublesome adverse neurologic effects, particularly movement disorders. In this article, we comprehensively review the indications and side effects of metoclopramide, and describe some common pitfalls and strategies to minimize the medicolegal risks to the prescribing physician. Metoclopramide accounts for nearly a third of all drug-induced movement disorders, a common reason for a malpractice suit. The entire spectrum of drug-induced movement disorders, ranging from subtle to life-threatening, can ensue from its use; akathisia and dystonia are generally seen early in the course of metoclopramide-induced movement disorders, whereas tardive dyskinesia and parkinsonism seem to be more prevalent in chronic users. Female sex, age and diabetes are the major risk factors for metoclopramide-induced movement disorders. It is therefore incumbent on gastroenterologists and other prescribing physicians to become familiar with the adverse neurologic effects associated with the use of metoclopramide, and to take appropriate preventive and defensive measures.

[Psychobiological significance of antipsychotics in multi-high dose drug therapy for schizophrenia]

In this session, the development of antipsychotics and 'atypicality' were discussed firstly. Various concepts regarding 'atypicality' had the meaning of optimal modulation of dopamine. Then, the key role of dopamine for psychotic symptoms and the question how antipsychotics should work for managing those symptoms were treated by introducing the theories by Kapur and Yagi. And from all these reasons, it came to the conclusion that megadose-polypharmacy treatment should be avoided.

[Two cases of tardive Tourette syndrome]

Tardive Tourette syndrome is an extrapyramidal symptom which appears after long-term neuroleptic use. We report two cases of this syndrome and review case reports to introduce this extrapyramidal symptom. The first case is a 40-year-old male with schizophrenia. After 6 years of neuroleptic therapy, he began to have barking and grunting vocalizations and show neck and shoulderjerking. The second case is a 53-year-old male with alcoholism. Sulpride was prescribed for three years to treat mood symptoms. Oral dyskinesia appeared after sulpride was stopped. About five weeks after amantadine and trihexyphenidyl hydrochloride was started, he began to have grunting vocalizations and show neck jerking. The involuntary movement disappeared quickly after intraveneous administration of haloperidol. Including our two cases, there are 17 case reports of tardive Tourette syndrome. Twelve cases were schizophrenic patients. In addition to typical movements, patients had coplolalia in 6 cases, and oral dyskinesia in 9 cases. In 8 cases, tardive Tourette syndrome appeared during neuroleptic treatment, and in 9 cases the syndrome appeared after neuroleptics were stopped. Our two cases and previous case reports showed that tardive Tourette syndrome appeared after long-term neuroleptic therapy, it was improved transiently by an increase of neuroleptics and exacerbated by their decrease, it was exacerbated by dopaminergic and anticholinergic drugs, and tardive dyskinesia was often seen concomitantly, indicating that tardive Tourette syndrome has a similar pathophysiology to tardive dyskinesia. Tardive Tourette syndrome should not be misdiagnosed as an exacerbation of schizophrenic symptoms responsive to an increase of neuroleptics. This side effect should be recognized widely and treated properly.

[Theory in antipsychotic drug therapy for schizophrenia]

In Japan, antipsychotic polypharmacy with high doses for schizophrenia has been traditionally used. However, antipsychotic polyphamacy with high doses provide disadvantages for patient. Recent PET studies show that dopamine D2 occupancy with antipsychotics is important for the treatment of schizophrenia. First, antipsychotics become effective only at which their D2 occupancy exceeds 65%. Second, antipsychotics with D2 occupancy below 90% rarely causes occupancy exceeds 65%. Second, antipsychotics with D2 occupancy below 90% rarely causes extrapyramidal side effect. These results suggest that monopharmacy which uses a single antipsychotic agent with appropriate dose is recommended for schizophrenia treatment.

From clinical research to clinical practice: a 4-year review of ziprasidone

Ziprasidone is a second-generation antipsychotic that received Food and Drug Administration approval in February 2001. It has a unique receptor profile that includes high-affinity antagonist activity at dopamine D2 receptors, inverse agonist activity at serotonin (5-HT)2A receptors, agonist activity at 5-HTlA receptors, and a relatively high affinity for the serotonin and norepinephrine transporters. The 5-HTIA affinity, together with the inhibitory effect on mono-amine reuptake, may underlie the hypothesized beneficial effects on comorbid affective and cognitive abnormalities in schizophrenia and schizoaffective disorder. The short-term efficacy of ziprasidone for core positive symptoms of schizophrenia appears to be comparable to other conventional and atypical antipsychotics. The short-term efficacy of ziprasidone in acute mania has been established based on two 3-week, double-blind, placebo-controlled trials.Open-label treatment for up to 52 weeks confirms the sustained efficacy and safety of ziprasidone in bipolar disorder. Maintenance studies in schizophrenia and schizoaffective disorder indicate that long-term ziprasidone therapy is effective in preventing relapse, while maintaining cognitive and psychosocial benefits. The safety database suggests that the overall cardiovascular and cerebrovascular risk associated with ziprasidone is lower than with other atypicals, with notably lower risk of drug-related increases in weight, glucose, or lipids. The data also suggest a modestly increased risk of QTc prolongation that is not dose related or linked to torsades de pointes. Switching to ziprasidone from other atypicals appears to improve both clinical symptoms and metabolic parameters, though more studies are needed to fully characterize these benefits. This monograph summarizes the efficacy, tolerability, and safety of oral ziprasidone in the treatment of schizophrenia, schizoaffective disorder, and bipolar mania.

Dissociation between medial temporal lobe and basal ganglia memory systems in schizophrenia

The purpose of this study was to investigate basal ganglia (BG) and medial temporal lobe (MTL) dependent learning in patients with schizophrenia. Acquired equivalence is a phenomenon in which prior training to treat two stimuli as equivalent (if two stimuli are associated with the same response) increases generalization between them. The learning of stimulus-response pairs is related to the BG, whereas the MTL system participates in stimulus generalization. Forty-three patients with DSM-IV schizophrenia and 28 matched healthy controls participated. Volunteers received the Rutgers acquired equivalence task (face-fish task) by [Myers, C.E., Shohamy, D., Gluck, M.A. et al., 2003. Dissociating hippocampal versus basal ganglia contributions to learning and transfer. J. Cogn. Neurosci. 15, 185-193.], the California Verbal Learning Test (CVLT), and the n-back working memory test. The Rutgers acquired equivalence task investigates BG-dependent processes (stimulus-response learning) and MTL-dependent processes (stimulus generalization) with a single test. Results revealed that patients with schizophrenia showed a selective deficit on stimulus generalization, whereas stimulus-response learning was spared. The stimulus generalization deficit correlated with the CVLT performance (total scores from trials 1-5 and long-delay recall), but not with the n-back test performance. The number of errors during stimulus-response learning correlated with the daily chlorpromazine-equivalent dose of antipsychotics. In conclusion, this is the first study to show that patients with schizophrenia exhibit deficits during MTL-dependent learning, but not during BG-dependent learning within a single task. High-dose first generation antipsychotics may disrupt BG-dependent learning by blocking dopaminergic neurotransmission in the nigro-stiratal system.

The search for novel antipsychotics: pharmacological and molecular targets

There can be little doubt that the newer, atypical, antipsychotic drugs provide improved treatment for many patients suffering from schizophrenia. However, the significant gains in tolerability produced by these drugs have not generally been accompanied by major advances in clinical efficacy. In particular, negative and cognitive symptoms, which may represent the core deficit of the disease, remain inadequately treated. There is, therefore, a pressing need for more effective drugs. A number of drug discovery and development programmes are currently underway in parallel with significant research into the basic neurobiology of the disease. All antipsychotic drugs currently used in the clinic are antagonists at dopamine D2 receptors, and dopamine neurotransmission seems likely to remain a major biological target for research. However, novel approaches to modulate dopaminergic neurotransmission selectively in relevant brain regions may be required. In addition, a range of non-dopaminergic targets including glutamate, serotonin, neurokinins and acetylcholine are also of major interest. It is likely, however, that the importance of many of these targets may lie in their relationships to and interactions with dopaminergic mechanisms. Finally, advances in genetics and molecular biology are identifying genes associated with a susceptibility to develop schizophrenia. It remains to be seen whether or not these genes and their associated proteins will provide molecular targets for successful drug discovery.

Human relevance of rodent prolactin-induced non-genotoxic mammary carcinogenesis: prolactin involvement in human breast cancer and significance for toxicology risk assessments

Prolactin-induced mammary carcinogenesis in rodents, particularly rats, is often stated to be of low toxicological relevance to humans. This opinion appears to have developed from a number of lines of cited evidence. Firstly, there had been long experience of use of dopamine antagonists (that increase prolactin) in human medicine and no evidence of an increase in breast cancer incidence or risk had been reported. Secondly, dopamine agonists (that lower prolactin) had been shown to have no effect in human breast cancer treatment. Thirdly, the actions of prolactin were considered different between rodents and humans. However, recent evidence now suggests that prolactin has a major role in human breast cancer, and the similarity of mechanism with the rodent suggests that prolactin-mediated mammary carcinogenesis in rodents could be of much higher toxicological relevance to humans than previously thought. Large epidemiology studies have upgraded a limited database and shown that dopamine antagonists (both antipsychotics and anti-emetics) increase breast cancer risk, that hyperprolactinaemia is consistently associated with human breast cancer growth, development and poor prognosis, and that prolactin is indeed a mitogen in human breast cancer cells that suppresses apoptosis and upregulates BRCA1. It is now clear that initial studies giving dopamine agonists to breast cancer patients had no effect because breast cancer cells also produced prolactin independently of the pituitary, which remained uncontrolled and unrecognized in early clinical studies. The evidence for the role of prolactin in human breast cancer is now strong and consistent, and is discussed and related to the risk assessment of drugs and chemicals. The conclusion is that it is invalid to suggest that prolactin-induced mammary carcinogenesis in rodents is of low relevance to humans because prolactin can induce an adverse response in the mammary tissue of both rodents and humans alike. Drugs and chemicals causing rodent prolactin-induced mammary carcinogenesis may therefore pose a risk to humans via the same mechanism if exposures also increase prolactin secretion in humans.

Probing for affective side effects of drugs used in geriatric practice: use of daily diaries to test for effects of metoclopramide and naproxen

The aim of this study was to develop the use of daily diaries of affects and events as measures of pharmacological effects on affective processes and to apply them to evaluate the possible affective toxicity of metoclopramide and naproxen, two medications commonly used in geriatric practice. In all, 105 adults aged 65 years or older were randomized to receive metoclopramide (up to 40 mg/day), naproxen (up to 1000 mg/day), or placebo under double-blind conditions for a period of 5 weeks. Patients were seen weekly for evaluations of affective and cognitive outcomes as well as safety. In addition, patients kept diaries with daily records of positive and negative affect and reports of significant daily events. Findings included mixed model analyses of drug assignment, time, events, and interactions for both positive affect and days with significant negative affect. Subjects exhibited high levels of adherence in completing daily diaries. Neither the pattern of dropouts nor the weekly assessments demonstrated significant drug effects on mood or affect. However, diary data demonstrated that metoclopramide increased the apparent impact of negative events on both positive and negative affect relative to placebo, and that naproxen increased the apparent impact of positive events on positive affect and, possibly, of negative events on negative affect relative to placebo. The findings confirm the utility of diary methods for studying drug effects on affective processes in normal elderly subjects. They suggest that both metoclopramide and naproxen can affect the associations between daily events and affects. If replicated, they would demonstrate that drug effects can extend beyond the intensity of affect and/or the emergence of full-fledged psychiatric disorders to include moderation of the interactions between daily events and affect.

[The optimal level of dopaminergic neurotransmission]

Dopaminergic neurotransmission affects an individual's subjective experience. Individuals with lower baseline dopamine function are at an increased risk for dysphoric responses during antipsychotic therapy with dopaminergic-blocking drugs. Reaching an optimal dopamine D2-receptor occupancy is therefore relevant for the quality of life. Doses of antipsychotic drugs administered to such individuals often need to be lower than the commonly used levels, as these may induce drowsiness and lack of energy.

A randomized, double-blind, placebo-controlled trial of metoclopramide for the treatment of Tourette's disorder

OBJECTIVE

The pattern of dopamine antagonism by metoclopramide suggests benefits in the treatment of tic disorders. The purpose of this study was to examine the efficacy and safety of metoclopramide in the treatment of children and adolescents with tic disorders.

METHOD

Twenty-seven medication-free patients (age 11.9 +/- 2.7 years) with Tourette's disorder or a chronic tic disorder participated in an 8-week double-blind, randomized, placebo-controlled trial of metoclopramide. Metoclopramide was started at 5 mg daily and titrated as needed to a maximum dose of 40 mg daily. Tics were rated every 2 weeks, and adverse effects, including weight, cardiac, and laboratory measures, were monitored.

RESULTS

After 8 weeks of treatment, subjects receiving metoclopramide showed a 39% reduction in their total tic score on the Yale Global Tic Severity Scale, while subjects receiving placebo showed only a 13% reduction in tic severity (p = .001). Metoclopramide was well tolerated with no significant laboratory or cardiac changes noted other than an increase in serum prolactin.

CONCLUSIONS

The results of this small controlled study suggest that metoclopramide is an effective and well-tolerated treatment for children and adolescents with tic disorders. Further trials are needed to confirm its efficacy and safety in pediatric patients and adults.

Coadministration of scrtraline with cisapride or pimozide: an open-label, nonrandomized examination of pharmacokinetics and corrected qt intervals in healthy adult volunteers

BACKGROUND

Sertraline hydrochloride is a selective serotonin reuptake inhibitor with demonstrated efficacy and safety for the treatment of the following disorders: major depressive, obsessive-compulsive, panic, premenstrual dysphoric, social anxiety, and posttraumatic stress. Although sertraline is unlikely to cause clinically significant inhibition of cytochrome P450 (CYP) 3A4 substrates, even modest concentration increases for narrow therapeutic index drugs, such as pimozide or cisapride, are potentially important.

OBJECTIVE

The goal of this study was to determine whether there is a pharmacokinetic interaction, as shown by plasma concentrations and electrocardiographic evidence of QTc intervals, between sertraline 200 mg QD and cisapride 10 mg QID, and between sertraline 200 mg QD and pimozide (single 2-mg dose).

METHODS

Patients in group A were administered cisapride on days 1 and 2 (10 mg QID), day 3 (10 mg/d), days 25 through 29 (10 mg QID), and day 30 (10 mg/d). Sertraline was administered on days 4 through 29 at a starting dose of 50 mg/d, which was titrated upward in 50-mg increments every third day to a maximum of 200 mg/d. Patients in group B were treated with 2 mg of pimozide on days 1 and 39. Sertraline was administered on days 18 through 46 at a starting dose of 50 mg/d, which was titrated upward in 50-mg increments every third day to a maximum of 200 mg/d.

RESULTS

There were 9 males and 6 females in group A (sertraline + cisapride) (mean age, 34.4 years for males, 41.7 years for females; mean weight, 78.7 kg for males, 66.6 kg for females; 14 Hispanic, 1 white), and 8 males and 7 females in group B (sertraline + pimozide) (mean age, 26.1 years for males, 33.4 years for females; mean weight, 70.8 kg for males, 61.4 kg for females; 15 Hispanic). Coadministration of sertraline and cisapride resulted in statistically significant reductions of 29% and 36% in cisapride C(max) and AUC from time 0 to 6 hours, respectively, compared with cisapride alone. Coadministration of sertraline and pimozide resulted in statistically significant increases of 35% and 37% in pimozide Cmax and AUC(0-infinity), respectively, compared with pimozide alone. No subject exhibited a prolongation of the QTc interval > or =15% with coadministration of sertraline and cisapride, or sertraline and pimozide.

CONCLUSIONS

This study found that coadministration of sertraline with cisapride resulted in decreases in cisapride concentrations, and no significant effects on QTc intervals. Coadministration of sertraline 200 mg/d and a single dose of pimozide 2 mg produced significant increases in pimozide concentrations but no prolongation of the QTc interval > or =15%. This opposite effect for pimozide compared with cisapride, as well as other previously tested CYP3A4 substrates, suggests that there are mechanisms other than CYP3A4 involved in the sertraline-pimozide interaction.

[Urinary retention in 2 children after the use of antiemetic agents during acute gastroenteritis]

Two girls, aged 2 and 4 years, with acute gastroenteritis and vomiting, received domperidone and metoclopramide, respectively. Urinary retention developed, but after catheterisation of the bladder was performed once and the medication was withdrawn, both children recovered without further sequelae. Anti-dopaminergic antiemetic agents should be prescribed with caution, especially in young children.

Metoclopramide induced dystonia in children: two case reports

Metoclopramide is a dopamine antagonist that is widely used in gastroesophageal disease and chemotherapy-induced emesis in the paediatric population. It is also prescribed in nausea and vomiting caused by respiratory tract infections and enteritis in practice. The primary side-effect of the drug is extrapyramidal reactions with incidences as high as 25% in children. We report two cases, one of which was referred to our emergency department as encephalitis and the other as tetany, but which were just acute dystonic reactions caused by metaclopramide, even though the patients had used the drug in the recommended dosages. The adverse effects of the drug can be seen at normal doses. These dystonic reactions caused by metaclopramide can easily be confused with other diseases, because dystonia is not seen frequently in paediatric practice whatever the cause.

Troubles extrapyramidaux sous véralipride (Agréal®), traitement symptomatique des bouffées de chaleur : à propos de 17 cas

PURPOSE

Extrapyramidal disorders associated with veralipride therapy are rarely reported and often due to a drug misuse.

METHODS

We evaluated cases of extrapyramidal disorders associated with veralipride. Cases were extracted from the regional pharmacovigilance centre of Amiens database. From January 1, 1995 to September 30, 2004, cases were selected on the basis of the occurrence of extrapyramidal disorders under veralipride therapy.

RESULTS

Seventeen cases of veralipride-induced extrapyramidal disorders were found. They consist of 16 menopausal women and one old man with LH-RH antagonist-induced hot flushes. Mean age was 61 years (48-73). Adverse effects were acute dyskinesia (n=2) or parkinsonian syndrome, which occurred after several months or years of treatment (n=15). Parkinsonism was associated with other extrapyramidal symptoms in 8 cases: tardive dyskinesia (n=6), postural tremor (n=3), myoclonia (n=1), and trunk dystonia (n=1). In all cases, outcome was favorable after drug discontinuation. In most cases the tablet-free interval was not respected: this may lead to prolonged striatal D2 receptors blockade. It must be added that the diagnosis was often delayed and patients were considered as suffering from idiopathic Parkinson's disease.

CONCLUSIONS

Prescribers should be aware that veralipride is a neuroleptic and could induce potentially severe extrapyramidal disorders. Increase veralipride prescription is expected due to the recent restriction of hormonal replacement therapy for menopause. The physicians should also use veralipride according to the Summary of the Product Characteristics.

Maternal immune activation leads to behavioral and pharmacological changes in the adult offspring

Maternal exposure to viral infection has been associated with an increased risk of schizophrenia in the offspring, and it has been suggested that the maternal immune response may interfere with normal fetal brain development. Although studies in rodents have shown that perinatal viral infections can lead to neuropathological and behavioral abnormalities considered relevant to schizophrenia, it is not clear whether these consequences are due to the infection itself or to the maternal immune response to infection. We show that an induction of maternal immune stimulation without exposure to a virus by injecting pregnant dams with the synthetic cytokine releaser polyriboinosinic-polyribocytidilic acid (poly I:C) leads to abnormal behavioral and pharmacological responses in the adult offspring. As in schizophrenia, these offspring displayed excessive behavioral switching, manifested in the loss of latent inhibition and in rapid reversal learning. Consistent with the clinical pharmacology of schizophrenia, both deficits were alleviated by antipsychotic treatment. In addition, these offspring displayed increased sensitivity to the locomotor-stimulating effects of MK-801, pointing to developmental alterations of the dopaminergic and/or glutamatergic systems. Prenatal poly I:C administration did not produce learning deficits in classical fear conditioning, active avoidance, discrimination learning and water maze. These results show that the maternal immune response is sufficient to cause behavioral and pharmacological alterations relevant to schizophrenia in the adult offspring.

In vivo confocal microstructural analysis of corneal endothelial changes in a patient on long-term chlorpromazine therapy

BACKGROUND

Deposits in the cornea and lens are a known complication of long-term chlorpromazine therapy.

METHOD

A 59-year-old woman had previously taken chlorpromazine for 20 years with doses up to 1,200 mg/day, with a mean dose of 400 mg/day. She presented with gradual onset of blurred vision in her left eye. Slit-lamp biomicroscopy revealed multiple fine creamy-white deposits on her corneal endothelium and anterior crystalline lens capsule bilaterally.

RESULTS

In vivo confocal microscopy of the cornea identified irregular hyper-reflective deposits on the posterior surface of the endothelium. The deposits varied from 1 microm to 70 microm in diameter and had well-defined edges. Endothelial morphology was otherwise normal bilaterally.

CONCLUSIONS

This is the first report of in vivo confocal imaging of deposits resulting from long-term chlorpromazine use. Microstructural analysis of the corneal endothelium reveals that there were no abnormalities in cellular morphology resulting from these deposits.

D2-blockade and possible ziprasidone-induced galactorrhea

This is the second report of possible ziprasidone-induced galactorrhea in an adult female. This case illustrates the need to consider dose as well as potency when interpreting the response of a patient to a drug, particularly when the response appears to be idiosyncratic.

Prospective, randomised, double blind, controlled comparison of metoclopramide and pethidine in the emergency treatment of acute primary vascular and tension type headache episodes

STUDY OBJECTIVE

To compare analgesic effects of metoclopramide (MTP), pethidine (PET), and combination of metoclopramide-pethidine (M-PET) in the treatment of adult patients with acute primary vascular and tension type headache admitted in the emergency department (ED).

METHODS

All consecutive adult patients admitted into a university hospital ED in six months with acute vascular and tension type headache were recruited. The patients whose complaints had lasted no longer than seven days were randomised to four groups and thereby received 10 mg MTP intravenously plus placebo intramuscularly (MTP), 10 mg MTP intravenously plus 50 mg PET intramuscularly (M-PET), 50 mg PET intramuscularly plus placebo intravenously (PET); and intramuscular and intravenous placebo (PLC) in a blinded fashion. The patients were asked to report the degree of pain at 0, 15, 30, and 45 minutes on visual analogue scale (VAS) and demographic data and any side effects encountered were recorded. Rescue medication was used if required by the patient because of poor pain relief.

RESULTS

Data regarding 336 patients meeting inclusion criteria were analysed. Mean VAS values recorded at 45 minutes were significantly higher in PLC group than in others (p = 0.000). When the PLC group was excluded, VAS scores in MTP and M-PET groups were significantly lower than in PET group (p = 0.038). Though unimportant, the incidence of side effects recorded in PET group was found to be significantly higher than in the other groups (p = 0.003).

CONCLUSION

These data suggest that MTP produces more effective analgesia than PET in both vascular and tension type headache in patients with acute primary headache episodes.

An open study of methotrimeprazine in the management of nausea and vomiting in patients with advanced cancer

INTRODUCTION

Nausea and vomiting are distressing symptoms affecting between 20% and 70% of patients with advanced cancer. Methotrimeprazine is a phenothiazine antipsychotic used in palliative care for the management of terminal agitation and nausea/vomiting but there is only anecdotal evidence to support its use in palliative care.

AIM

To establish whether nausea/vomiting in palliative care patients is improved by the administration of low-dose methotrimeprazine.

METHODS

Patients with advanced malignancy were entered at different treatment levels according to symptom severity. The dose was altered according to response (minimum dose 6.25 mg daily po, maximum 25 mg by 24-h subcutaneous infusion). Symptoms and side effects were recorded daily from 0 (baseline) to day 5 using a four-point scale. Any improvement in nausea/vomiting score was taken as a response.

RESULTS

Sixty-five patients were entered. The cause of nausea and vomiting was multifactorial in the majority of patients, 35/65 (54%). As expected in a study of patients with poor performance status, the attrition rate was high. Of 53 patients evaluable for response at day 2, 33 (62%) showed some improvement in nausea or vomiting. At day 5, improvement was seen in 20/34 (58%). There was no significant change in "side effects" from baseline with time.

CONCLUSION

These results suggest that methotrimeprazine has antiemetic activity.

A trial of metoclopramide vs sumatriptan for the emergency department treatment of migraines

OBJECTIVE

To compare the efficacy of 20 mg of IV metoclopramide, given up to four times over 2 hours as needed for persistent headache, with 6 mg of subcutaneous sumatriptan for the emergency department treatment of migraine headaches.

METHODS

This was a randomized, double-blind, clinical trial with two intervention arms. The primary endpoint was change in pain intensity as measured by an 11-point pain scale at 2 hours. Secondary endpoints included change in pain intensity at 24 hours and rates of pain-free headache relief at 2 and 24 hours.

RESULTS

Two hundred two patients were screened, and 78 of 91 eligible patients were randomized. The two groups had comparable pain scores at baseline. By 2 hours, the change in pain intensity for the metoclopramide group was 7.2 compared with 6.3 for the sumatriptan group (95% CI for difference: -0.2 to 2.2). When compared at 24 hours, the metoclopramide group had improved by 6.1 compared with baseline and the sumatriptan group had improved by 5.0 (95% CI for difference: -0.6 to 2.8). At 2 hours, pain-free rates were 59% in the metoclopramide arm and 35% in the sumatriptan arm (95% CI for difference of 24%: 2 to 46%). The most common side effects at both time points were weakness, dizziness, and drowsiness, which were distributed evenly between the two groups. There were no reports of chest pain within the first 2 hours. The incidence of restlessness, stiffness, and abnormal movements was distributed equally between the two groups.

CONCLUSIONS

When compared at 2 and 24 hours, aggressive (20 mg dosed up to four times) IV metoclopramide and 6 mg of subcutaneous sumatriptan relieved migraine headache pain comparably. Some secondary endpoints suggest that metoclopramide may be the preferable therapy for migraines presenting to the emergency department.

Prevalence of bruxism in children receiving treatment for attention deficit hyperactivity disorder: a pilot study

The objective of this study was to evaluate reported bruxism among children affected by attention deficit hyperactivity disorder (ADHD). Thirty children diagnosed with ADHD and 30 healthy age and gender matched controls participated in the study. All subjects were examined for dental attrition, and the parents were asked for signs and symptoms of bruxism in their children using a questionnaire. Prevalence of oral parafunction was evaluated comparing ADHD children taking medications, ADHD children not taking medications, and controls. Subjects affected by ADHD and pharmacologically treated showed higher occurrence of bruxism compared to subjects affected by ADHD not taking medicines and controls; and within the ADHD group taking medications, CNS-stimulants have been associated with such side effect more frequently than the other drugs.

Neuroleptic Malignant Syndrome after Haloperidol and Fentanyl Infusion in a Patient with Cancer with Severe Mineral Imbalance

This case report describes a terminally ill patient with cancer with severe hypophosphataemia, hypocalcemia, and hypomagnesemia who developed neuroleptic malignant syndrome after administration of a combination of haloperidol and fentanyl. The chief etiology of neuroleptic malignant syndrome in this patient was administration of haloperidol, but fentanyl and coexisting mineral imbalance could have contributed to development of the syndrome. Palliative care clinicians should be aware that neuroleptic malignant syndrome can occur in their patients receiving haloperidol.

[Orthostatic tremor induced by pharmaceuticals]

INTRODUCTION

Dopamine blocking agents can induce gravel types of 'tardive syndromes' (buccolinguomasticatory syndrome, dystonia, akathisia, and less frequently tremor, tourettism, and myoclonus). To our knowledge, orthostatic tremor has not been previously described as a complication of exposure to these drugs.

CASE REPORTS

We report four patients who developed orthostatic tremor after exposure to dopamine blocking drugs. Two of them had orthostatic tremor as the predominant but not exclusive type of tremor, and the other two had 'pure' high-frequency orthostatic tremor. Tremor disappeared completely in 3 patients and improved markedly in the other one after gradual withdrawal of the offending drugs (metoclopramide in case 1, sulpiride and thyethylperazine in case 2, and sulpiride in cases 3 and 4).

CONCLUSIONS

We propose that this 'tardive orthostatic tremor' could be considered into the spectrum of drug-induced movement disorders.