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Ismail O, Albdour K, Jaber Y, Jaber K, Alsaras A. Efficacy and safety of different pharmacological interventions in the treatment of tardive dyskinesia: a systematic review and network meta-analysis. Eur J Clin Pharmacol 2024:10.1007/s00228-024-03722-5. [PMID: 38969949 DOI: 10.1007/s00228-024-03722-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Accepted: 06/23/2024] [Indexed: 07/07/2024]
Abstract
OBJECTIVES The aim of this study is to indirectly compare and rank the different drugs that have been studied in randomized clinical trials (RCTs) in patients with tardive dyskinesia (TD) in terms of their efficacy in ameliorating the symptoms of TD and safety. DESIGN A network meta-analysis and a systematic review were registered prospectively on PROSPERO under the ID: CRD42023407823 and were conducted in accordance with the PRISMA-NMA guidelines. DATA SOURCES PubMed, Scopus, The Cochrane Central Register of Controlled Trials (CENTRAL), Web of Sciences, and Clinicaltrials.gov were searched to identify relevant records. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Any parallel randomized blinded controlled clinical trials that studied the use of any medications in treating TD and assessed the symptoms using a functional scale that has been previously validated. DATA EXTRACTION The standardized mean difference of improvement along with the reported adverse events for each drug was extracted from each trial, and a network meta-analysis was conducted using a random-effects model. RESULTS One thousand eight hundred seventeen patients in 33 RCTs were included in the analysis. Twenty-three different drugs were compared to placebo in terms of reduction in TD symptoms. Among these, valbenazine 80 mg (SMD = - 1.66, 95%CI = [- 2.55; - 0.78]), valbenazine 40 mg (- 1.00, [- 1.89; - 0.11]), and vitamin E (- 0.77, [- 1.45; - 0.1]) significantly reduced TD symptoms in comparison to placebo, while deutetrabenazine 36 mg (- 1.00, [- 2.12; 0.11]) and reserpine (- 0.54, [- 1.09; 0.02]) did not significantly reduce symptoms. Some serious adverse events were reported for valbenazine and deutetrabenazine, which included mainly psychiatric symptoms such as depression, worsening of schizophrenia, and suicidal ideation, while mild adverse events were reported for other drugs, and their incidence in the treatment arms was comparable to those in the placebo arm. CONCLUSIONS Valbenazine (80 and 40 mg) and vitamin E demonstrated efficacy in treating tardive dyskinesia. However, the significant side effects of valbenazine should prompt further investigation of alternative treatment modalities.
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Affiliation(s)
- Omar Ismail
- School of Medicine, The University of Jordan, Amman, Jordan, Queen Rania Street, 11942
| | - Karam Albdour
- School of Medicine, The University of Jordan, Amman, Jordan, Queen Rania Street, 11942.
| | - Yazan Jaber
- School of Medicine, The University of Jordan, Amman, Jordan, Queen Rania Street, 11942
| | - Kamel Jaber
- School of Medicine, The University of Jordan, Amman, Jordan, Queen Rania Street, 11942
| | - Ameen Alsaras
- School of Medicine, The University of Jordan, Amman, Jordan, Queen Rania Street, 11942
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Petriceks A, Vyas CM, Paudel S, Donovan AL, Van Alphen MU, Stern TA. Assessment and Treatment of Abnormal Involuntary Movements: A Clinically Focused Narrative Review. Harv Rev Psychiatry 2024; 32:47-57. [PMID: 38452284 DOI: 10.1097/hrp.0000000000000390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
LEARNING OBJECTIVES After participating in this CME activity, the psychiatrist should be better able to:• Categorize and describe different types of abnormal involuntary movements (AIMs).• Identify assessment tools and treatment options for AIMs. ABSTRACT Abnormal involuntary movements (AIMs) comprise a diverse group of movement disorders characterized by uncontrolled and unintended movements (e.g., tremors, tics, dystonia). AIMs can occur at any stage of life and pose significant challenges for clinicians. It is difficult to determine their underlying causes due to the complex neurobiological mechanisms involved. Therefore, it is crucial to quantify the severity and progression of AIMs using well-validated measurement scales, such as the Abnormal Involuntary Movement Scale (AIMS). By employing reliable assessment approaches, clinicians can objectively evaluate the motoric manifestations of AIMs and track them over time. Treatment of AIMs varies depending on their nature and etiology. While AIMs often respond to treatment, serious side effects can undermine treatment efficacy. In this clinically focused narrative review, we categorize different types of AIMs and discuss their neurobiological aspects. Further, we emphasize the importance of using well-validated measurement scales for accurate assessment and discuss available treatment modalities that target the specific AIMs manifestations. Additionally, we cover the need for comprehensive care to address the multifaceted nature of AIMs, accounting for their physical manifestations as well as their psychological, social, and functional toll on patients. By embracing a multidisciplinary approach, health care professionals can provide patient-centered care that promotes overall well-being and enhances the lives of patients coping with AIMs. Regular follow-up assessments are necessary to monitor treatment response, adjust medications when needed, and provide ongoing support for individuals affected by AIMs.
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Affiliation(s)
- Aldis Petriceks
- From Harvard Medical School, Boston, MA (Mr. Petriceks, Drs. Vyas, Paudel, Donovan, Van Alphen, and Stern); Department of Psychiatry, Massachusetts General Hospital, Boston, MA (Drs. Vyas, Paudel, Donovan, Van Alphen, and Stern); Atrius Health, Boston, MA (Dr. Van Alphen)
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Fluphenazine-Induced Neurotoxicity with Acute Almost Transient Parkinsonism and Permanent Memory Loss: Lessons from a Case Report. Int J Mol Sci 2023; 24:ijms24032968. [PMID: 36769288 PMCID: PMC9917624 DOI: 10.3390/ijms24032968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 01/11/2023] [Accepted: 01/31/2023] [Indexed: 02/05/2023] Open
Abstract
We report the singular case of a 31-year-old woman who developed very serious Fluphenazine-induced parkinsonism over a few days due to a doubly incongruent drug prescription by indication and dosage having been applied to a healthy subject over one week instead of seven months. Unlike gradual drug-induced parkinsonism, our patient experienced acute extrapyramidal syndrome (EPS), reaching significant motor and sphincter disability in just a few days, followed by a gradual incomplete recovery over more than six months. In fact, after drug discontinuation, hypomimia and slight left hemi-somatic rigidity with bradykinesia remained, as well as stable non-progressive memory disturbances. Despite bio-humoral and instrumental investigations and DaTScan were negative, MRI post-analysis evidenced a 6.5% loss in brain volume. Specifically, irreversible cortical and sub-cortical grey matter reduction and cerebrospinal fluid space enlargement with spared white matter were found. Our observations suggest that the sudden availability of Fluphenazine results in a kind of plateau effect of parkinsonism presentation, partially reversible due to the neurotoxic drug effect on the cortical and sub-cortical grey matter, resulting in asymmetric EPS and stable memory loss, respectively. Our report confirms the debated neurotoxicity of first-generation neuroleptics and the postulated theory of differential susceptibility to the cytotoxic stressors on the central nervous system.
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Ri K, Fukasawa T, Yoshida S, Takeuchi M, Kawakami K. Risk of parkinsonism and related movement disorders with gabapentinoids or tramadol: A case-crossover study. Pharmacotherapy 2023; 43:136-144. [PMID: 36633384 DOI: 10.1002/phar.2761] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 12/17/2022] [Accepted: 12/18/2022] [Indexed: 01/13/2023]
Abstract
INTRODUCTION A safety signal concerning parkinsonism and related movement disorders with gabapentinoids (gabapentin and pregabalin) or tramadol was detected by reviewing individual case reports and data mining in spontaneous report databases. Well-designed pharmacoepidemiological studies are needed to assess the signal. OBJECTIVE This study aimed to investigate the association of exposure to gabapentinoids or tramadol with the risk of parkinsonism and related movement disorders. METHODS We conducted a case-crossover study using a Japanese electronic medical records database. Patients with newly diagnosed parkinsonism or related movement disorders between January 1, 2007, and April 14, 2019, were identified. The diagnosis date of outcomes was defined as the index date. We assessed the exposure of each patient to gabapentinoids or tramadol during a 90-day hazard period ending 1 day before the index date and in three 90-day reference periods. Multivariable conditional logistic regression models were employed to estimate adjusted odds ratios (aORs) and 95% confidence intervals (CIs). To confirm the robustness of the primary findings, we also performed sensitivity analyses using a case-case-time-control design, a different time window for hazard and reference periods, a different definition of outcome, and different number of reference periods. RESULTS A total of 28,972 eligible cases were included in the primary analysis. Exposure to gabapentinoids (aOR, 2.12; 95% CI, 1.73-2.61) and tramadol (aOR, 2.04; 95% CI, 1.57-2.64) was associated with increased risk. Results were consistent across sensitivity analyses. CONCLUSION Our findings serve as a caution to physicians who prescribe gabapentinoids or tramadol in routine clinical practice.
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Affiliation(s)
- Kairi Ri
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, Japan
| | - Toshiki Fukasawa
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, Japan.,Department of Digital Health and Epidemiology, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, Japan
| | - Satomi Yoshida
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, Japan.,Department of Digital Health and Epidemiology, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, Japan
| | - Masato Takeuchi
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, Japan
| | - Koji Kawakami
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, Japan
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Pathophysiological Mechanisms of Antipsychotic-Induced Parkinsonism. Biomedicines 2022; 10:biomedicines10082010. [PMID: 36009557 PMCID: PMC9405702 DOI: 10.3390/biomedicines10082010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 07/25/2022] [Accepted: 08/10/2022] [Indexed: 01/02/2023] Open
Abstract
Among neurological adverse reactions in patients with schizophrenia treated with antipsychotics (APs), drug-induced parkinsonism (DIP) is the most common motility disorder caused by drugs affecting dopamine receptors. One of the causes of DIP is the disruption of neurotransmitter interactions that regulate the signaling pathways of the dopaminergic, cholinergic, GABAergic, adenosinergic, endocannabinoid, and other neurotransmitter systems. Presently, the development mechanisms remain poorly understood despite the presence of the considered theories of DIP pathogenesis.
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Gait abnormalities and non-motor symptoms predict abnormal dopaminergic imaging in presumed drug-induced Parkinsonism. NPJ Parkinsons Dis 2022; 8:53. [PMID: 35484281 PMCID: PMC9051164 DOI: 10.1038/s41531-022-00309-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 02/01/2022] [Indexed: 12/25/2022] Open
Abstract
Drug-induced parkinsonism (DIP) can be clinically indistinguishable from degenerative parkinsonism, and bedside assessments are needed to differentiate between these conditions. We examined 34 U.S. Veterans with DIP using 123I-FP-CIT (DAT-SPECT) to identify underlying nigrostriatal degeneration. Participants were 94% male with mean age of 64.5 ± 7.1 years. DAT-SPECT was abnormal in 12/34 (35%). Comparing normal and abnormal imaging groups, there were no differences in age, sex, race/ethnicity, psychiatric diagnosis, motor severity, or RBD Screening Questionnaire scores. Those with underlying neurodegeneration reported significantly more non-motor symptoms (NMS), worse olfactory function on the University of Pennsylvania Smell Identification Test, and greater turning duration/steps on the instrumented Timed Up and Go. Area under the curve (AUC) combining poor olfaction and total NMS burden was 0.84 (CI 0.71-0.97), while AUC for turn steps was 0.91 (CI 0.81-1.00). Gait impairment, hyposmia, and NMS may be useful alone and in combination to identify DIP patients with underlying dopaminergic degeneration.
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Huh Y, Kim DH, Choi M, Park JH, Kwon DY, Jung JH, Han K, Park YG. Metoclopramide and Levosulpiride Use and Subsequent Levodopa Prescription in the Korean Elderly: The Prescribing Cascade. J Clin Med 2019; 8:E1496. [PMID: 31546900 PMCID: PMC6780178 DOI: 10.3390/jcm8091496] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 09/15/2019] [Accepted: 09/16/2019] [Indexed: 11/30/2022] Open
Abstract
The aim of this study was to investigate the prescribing cascade phenomenon of dopaminergic drugs such as levodopa in the management of gastroprokinetic drugs induced parkinsonism. Based on the Korea National Health Insurance Service (NHIS)-Senior Cohort Database, we analyzed patients aged ≥65 years, between 2009 and 2013, who obtained new prescriptions for levodopa through the NHIS during this period. Those who were prescribed levodopa from 2002 to 2008 were excluded, only patients who were prescribed metoclopramide and levosulpiride within 90 days of receiving the levodopa prescription were included. Those who did not receive levodopa were used as a control group for 1:3 age and sex matching. We assessed 1824 and 1197 levodopa cases for metoclopramide and levosulpiride use, respectively. The matched controls for each levodopa case were 5472 and 3591, respectively. We used conditional logistic regression to determine the odds ratio (OR) for initiation of levodopa therapy in patients using metoclopramide and levosulpiride, relative to nonusers, after adjusting for age, sex, and exposure to antipsychotic medication. Both metoclopramide (OR = 3.04; 95% confidence interval, CI, 2.46-3.77) and levosulpiride (OR = 3.32; 95% CI, 2.56-4.3) users were three times more likely to begin using medication containing levodopa, compared to nonusers. Metoclopramide and levosulpiride were frequently prescribed within 90 days of receiving a prescription for levodopa. Before prescribing levodopa, it should be considered whether the adverse event is actually a side effect caused by metoclopramide and levosulpiride.
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Affiliation(s)
- Youn Huh
- Department of Family Medicine, Inje University Ilsan Paik Hospital, College of Medicine, Inje University, 170, Juhwa-ro, Ilsanseo-gu, Goyang-si, Gyeonggi-do 10380, Korea.
| | - Do-Hoon Kim
- Department of Family Medicine, Korea University Ansan Hospital, Korea University College of Medicine, 123, Jeokgeum-ro, Danwon-gu, Ansan-si, Gyeonggi-do 15355, Korea.
| | - Moonyoung Choi
- Department of Family Medicine, Korea University Ansan Hospital, Korea University College of Medicine, 123, Jeokgeum-ro, Danwon-gu, Ansan-si, Gyeonggi-do 15355, Korea.
| | - Joo-Hyun Park
- Department of Family Medicine, Korea University Ansan Hospital, Korea University College of Medicine, 123, Jeokgeum-ro, Danwon-gu, Ansan-si, Gyeonggi-do 15355, Korea.
| | - Do-Young Kwon
- Department of Neurology, Korea University Ansan Hospital, Korea University College of Medicine, 123, Jeokgeum-ro, Danwon-gu, Ansan-si, Gyeonggi-do 15355, Korea.
| | - Jin-Hyung Jung
- Department of Biostatistics, College of Medicine, The Catholic University of Korea, Seoul 03083, Korea.
| | - Kyungdo Han
- Department of Biostatistics, College of Medicine, The Catholic University of Korea, Seoul 03083, Korea.
| | - Yong-Gyu Park
- Department of Biostatistics, College of Medicine, The Catholic University of Korea, Seoul 03083, Korea.
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Jhang KM, Huang JY, Nfor ON, Tung YC, Ku WY, Jan CF, Liaw YP. Flunarizine related movement disorders: a nationwide population-based study. Sci Rep 2019; 9:1705. [PMID: 30737414 PMCID: PMC6368567 DOI: 10.1038/s41598-018-37901-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Accepted: 12/04/2018] [Indexed: 11/05/2022] Open
Abstract
Flunarizine (fz) causes side effects such as movement disorders (MDs). We investigated risk factors associated with fz-related MDs. Participants were recruited from the longitudinal health insurance databases and included patients who took fz for more than 1 month. Patients with one of the underlying diseases, or with concomitant drug use (antipsychotics, metoclopramide or reserpine), and those diagnosed with MDs before fz use were excluded. Fz-related MD was defined as a new diagnosis of parkinsonism or hyperkinetic syndrome including dyskinesia or secondary dystonia during fz use or within 3 months after drug discontinuation. After exposure, 288 individuals had fz-related MDs (parkinsonism, n = 240; hyperkinesia, n = 48). Risk factors associated with these disorders were higher-dose exposure (cumulative defined daily dose [cDDD] ≥87.75, odds ratio [OR]: 3.80; 95% CI: 2.61–5.52), older age (OR: 1.07; 95% CI: 1.06–1.09), history of essential tremor (OR: 6.39; 95% CI: 2.29–17.78) and cardiovascular disease (CVD) (OR: 1.47; 95% CI: 1.14–1.9). The optimal value of cDDD to predict MDs was 58.5 (sensitivity: 0.67, specificity: 0.60), indicating an overall exposure of 585 mg. Higher exposure dose and duration, older age, history of essential tremor, and CVD were associated with fz-associated MDs. Clinicians ought to watch for extrapyramidal side effects when prescribing fz.
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Affiliation(s)
- Kai-Ming Jhang
- Department of Public Health and Institute of Public Health, Chung Shan Medical University, Taichung City, Taiwan.,Department of Neurology, Lu-Tung Christian Hospital, Changhua, Taiwan
| | - Jing-Yang Huang
- Department of Public Health and Institute of Public Health, Chung Shan Medical University, Taichung City, Taiwan
| | - Oswald Ndi Nfor
- Department of Public Health and Institute of Public Health, Chung Shan Medical University, Taichung City, Taiwan
| | - Yu-Chun Tung
- Department of Pharmacy, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Wen-Yuan Ku
- Department of Public Health and Institute of Public Health, Chung Shan Medical University, Taichung City, Taiwan
| | | | - Yung-Po Liaw
- Department of Public Health and Institute of Public Health, Chung Shan Medical University, Taichung City, Taiwan. .,Department of Family and Community Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan.
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Singh R. Tramadol-induced parkinsonism: a case report of a 75-year-old woman. J Basic Clin Physiol Pharmacol 2018; 30:275-278. [PMID: 30447142 DOI: 10.1515/jbcpp-2018-0113] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Accepted: 10/19/2018] [Indexed: 12/16/2022]
Abstract
Adverse drug reaction (ADR) is a form of unwanted reaction and is the crucial reason for illness and death. Tramadol-induced parkinsonism is a kind of ADR that occurs after the repeated intake of tramadol. Long-term exposure to tramadol has been known to induce tremor and alter the functioning of dopamine. This case report introduces a 75-year-old woman diagnosed with tramadol-induced parkinsonism due to the administration of tramadol for the treatment of post-operated (breast cancer) acute onset of severe pain on the left side of the chest. The assessment of the offending drug was carried out via Naranjo probability scale. A score of 6 was reported for this patient, defining tramadol as a probable cause of this reaction. For the management of the drug-induced parkinsonism, levodopa/carbidopa was prescribed and the symptoms related to parkinsonism resolved within a week. The age of the patient and the female gender is considered to be the main risk factor for the occurrence of such reaction. This case report is an attempt to spread awareness about the negative consequences of long-term use of tramadol in old patients. Thus, the medical practitioners must be very careful while administering tramadol to the old aged population.
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Affiliation(s)
- Ranbir Singh
- Department of Pharmacy Practice, ISF College of Pharmacy, Moga-Ferozepur G.T. Road, Moga-142001, Punjab, India, Phone: +91 978-046-7362
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Kadra G, Spiros A, Shetty H, Iqbal E, Hayes RD, Stewart R, Geerts H. Predicting parkinsonism side-effects of antipsychotic polypharmacy prescribed in secondary mental healthcare. J Psychopharmacol 2018; 32:1191-1196. [PMID: 30232932 PMCID: PMC6238161 DOI: 10.1177/0269881118796809] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Computer-modelling approaches have the potential to predict the interactions between different antipsychotics and provide guidance for polypharmacy. AIMS To evaluate the accuracy of the quantitative systems pharmacology platform to predict parkinsonism side-effects in patients prescribed antipsychotic polypharmacy. METHODS Using anonymized data from South London and Maudsley NHS Foundation Trust electronic health records we applied quantitative systems pharmacology, a neurophysiology-based computer model of humanized neuronal circuits, to predict the risk for parkinsonism symptoms in patients with schizophrenia prescribed two concomitant antipsychotics. The performance of the quantitative systems pharmacology model was compared with the performance of simple parameters such as: combination of affinity constants (1/Ksum); sum of D2R occupancies (D2R) and chlorpromazine equivalent dose. RESULTS We identified 832 patients with schizophrenia who were receiving two antipsychotics for six or more months, between 1 January 2007 and 31 December 2014. The area under the receiver operating characteristic (AUROC) curve for the quantitative systems pharmacology model was 0.66 ( p = 0.01), while AUROCs for D2R, 1/Ksum and chlorpromazine equivalent dose were 0.52 ( p = 0.350), 0.53 ( p = 0.347) and 0.52 ( p = 0.330) respectively. CONCLUSION Our results indicate that quantitative systems pharmacology has the potential to predict the risk of parkinsonism associated with antipsychotic polypharmacy from minimal source information, and thus might have potential decision-support applicability in clinical settings.
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Affiliation(s)
- Giouliana Kadra
- King’s College London, Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, London, UK,Giouliana Kadra, BRC Neucleus, Mapother House, De Crespigny Park, IOPPN, King’s College London, London, SE5 8AF, UK.
| | | | - Hitesh Shetty
- South London and Maudsley NHS Trust, BRC Nucleus, London, UK
| | - Ehtesham Iqbal
- King’s College London, SGDP, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - Richard D Hayes
- King’s College London, Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - Robert Stewart
- King’s College London, Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, London, UK,South London and Maudsley NHS Trust, BRC Nucleus, London, UK
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Antipsychotic-Related Movement Disorders: Drug-Induced Parkinsonism vs. Tardive Dyskinesia-Key Differences in Pathophysiology and Clinical Management. Neurol Ther 2018; 7:233-248. [PMID: 30027457 PMCID: PMC6283785 DOI: 10.1007/s40120-018-0105-0] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Indexed: 12/26/2022] Open
Abstract
Introduction Drug-induced parkinsonism (DIP) and tardive dyskinesia (TD) are stigmatizing movement disorders associated with exposure to dopamine receptor blocking agents such as antipsychotics, but they differ in their pathophysiology and clinical management. Treatment for one may worsen the other, and there are important diagnostic clues that assist in making an accurate assessment and instituting a rational treatment plan. Methods A literature review was executed to identify articles relating to the presentation, pathophysiology, epidemiology, and management of DIP and TD. Results DIP and TD prevalence estimates range from approximately 20 to 35% among antipsychotic users, but may be higher in select populations. DIP often presents as bradykinesia and rigidity, as well as rhythmic tremor, and the majority of cases appear within hours to weeks of initiation of therapy with an antipsychotic, or if dosage of the antipsychotic is increased. TD onset is delayed, typically appearing after at least 3 months or longer of treatment, and patients will commonly present with involuntary, abnormal facial movements such as lip smacking, puckering, chewing, or tongue protrusion. DIP often resolves with discontinuation of the causative agent, but TD may be permanent. Broadly, proposed mechanisms underlying these adverse events include decreased dopamine concentrations in the nigrostriatal pathway of the striatum and dopamine hypersensitivity, for DIP and TD, respectively. Pharmacologic treatment approaches for DIP have commonly included anticholinergic agents such as benztropine; however, anticholinergic medications can make TD worse. Switching the antipsychotic medication to one with lower propensity for DIP is an option for some patients. Amantadine, a non-anticholinergic agent used for the treatment of DIP, may be preferred in patients with comorbid DIP and TD. In TD, treatment options include the new reversible vesicular monoamine 2 transporter inhibitors, valbenazine and deutetrabenazine. Conclusions It is important for clinicians to be able to recognize DIP and TD in patients using antipsychotics so that they can minimize the impact of these adverse events on their patients’ quality of life. Accurate diagnosis will drive the selection of the correct treatment. Plain Language Summary Plain language summary available for this article.
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Chung SJ, Yoo HS, Moon H, Oh JS, Kim JS, Park YH, Hong JY, Ye BS, Sohn YH, Lee PH. Early-onset drug-induced parkinsonism after exposure to offenders implies nigrostriatal dopaminergic dysfunction. J Neurol Neurosurg Psychiatry 2018; 89:169-174. [PMID: 28912301 DOI: 10.1136/jnnp-2017-315873] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Revised: 06/11/2017] [Accepted: 08/30/2017] [Indexed: 11/04/2022]
Abstract
OBJECTIVES The onset of parkinsonism in patients with drug-induced parkinsonism (DIP) exhibits extensive individual variability following exposure to offending drugs. We investigated whether the individual variations in the onset time of parkinsonism reflected the underlying subtle dopaminergic dysfunction in DIP. METHODS We enrolled 71 patients with DIP who had visually normal striatal dopamine transporter (DAT) availability in 18F-FP-CIT positron emission tomography scans. According to their exposure durations to the offending drugs prior to onset of the parkinsonism, the patients were divided into the early-onset group (duration ≤6 months; n=35) and delayed-onset group (duration >6 months; n=36). We performed the quantitative analysis of the DAT availability in each striatal subregion between the groups. RESULTS No patients with DIP had DAT availability that was more than 2 SD below the normal mean of DAT availability. Compared with the delayed-onset group, the early-onset DIP group had decreased DAT availability in the striatal subregions including the posterior putamen (p=0.018), anterior putamen (p=0.011), caudate (p=0.035) and ventral striatum (p=0.027). After adjusting for age, sex and cross-cultural smell identification test scores, a multivariate analysis revealed that the DAT availability in the striatal subregions of the patients with DIP was significantly and positively associated with the natural logarithm of the duration of drug exposure. CONCLUSIONS These results suggest that a short exposure to the offending drugs before the development of parkinsonism would be associated with subtle nigrostriatal dopaminergic dysfunction in patients with DIP.
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Affiliation(s)
- Seok Jong Chung
- Department of Neurology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Han Soo Yoo
- Department of Neurology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hyojeong Moon
- Department of Nuclear Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jungsu S Oh
- Department of Nuclear Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jae Seung Kim
- Department of Nuclear Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Yong Hee Park
- Department of Neurology, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
| | - Jin Yong Hong
- Department of Neurology, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
| | - Byoung Seok Ye
- Department of Neurology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Young H Sohn
- Department of Neurology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Phil Hyu Lee
- Department of Neurology, Yonsei University College of Medicine, Seoul, Republic of Korea.,Severance Biomedical Science Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
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Pieters LE, Bakker PR, van Harten PN. Asymmetric Drug-Induced Parkinsonism and Psychopathology: A Prospective Naturalistic Study in Long-Stay Psychiatric Patients. Front Psychiatry 2018; 9:18. [PMID: 29459835 PMCID: PMC5807329 DOI: 10.3389/fpsyt.2018.00018] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Accepted: 01/18/2018] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Drug-induced parkinsonism (DIP) is the most common movement disorder induced by antipsychotics. Although DIP is mostly symmetric, asymmetric DIP is reported in a substantial part of the patients. We investigated the frequency of motor asymmetry in DIP and its relationship to the severity of psychopathology in long-stay psychiatric patients. METHODS We obtained data from a cohort study of 207 long-stay psychiatric patients on the frequency and risk factors of tardive dyskinesia, akathisia, tardive dystonia, and DIP. From July 2003 to May 2007 (mean follow-up, 1.1 year) drug-induced movement disorders were assessed at least two times in each patient, with a frequency of persistent DIP of 56.2%. All patients who had at least one time parkinsonism in the upper/lower limb(s) were included for analyses (190 patients, 79 women; mean age, 48.0 ± 12.9 years). The Unified Parkinson Disease Rating Scale motor scale was used to calculate the frequency of asymmetric parkinsonism. Multilevel mixed models were built to explore the relationship between asymmetry in parkinsonism and the severity of psychopathology, measured on the Clinical Global Impression-Schizophrenia scale severity index (CGI-SCH SI). RESULTS The frequency of asymmetric parkinsonism was 20.8%. Asymmetry in parkinsonism was associated with symptom severity on all CGI-SCH SI scales (β range, 0.37-3.74) and significantly associated with the positive symptom scale (β, 3.74; 95% CI, 0.35-7.31). CONCLUSION DIP is asymmetric in a substantial part of patients. Asymmetric presentation of DIP is of clinical relevance as it is related to the severity of psychopathology and may alert the clinician of more severe psychopathology. Future research is recommended to provide insight into the neuropsychopathology and clinical value of asymmetric parkinsonism for psychiatric patients.
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Affiliation(s)
- Lydia E Pieters
- Faculty of Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - P Roberto Bakker
- Psychiatric Center GGz Centraal, Amersfoort, Netherlands.,Department of Psychiatry and Psychology, Maastricht University Medical Center, South Limburg Mental Health and Teaching Network, Maastricht, Netherlands
| | - Peter N van Harten
- Psychiatric Center GGz Centraal, Amersfoort, Netherlands.,Department of Psychiatry and Psychology, Maastricht University Medical Center, South Limburg Mental Health and Teaching Network, Maastricht, Netherlands
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14
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Takada R, Yamamuro K, Kishimoto T. Long-lasting extrapyramidal symptoms after multiple injections of paliperidone palmitate to treat schizophrenia. Neuropsychiatr Dis Treat 2018; 14:2541-2544. [PMID: 30323602 PMCID: PMC6174309 DOI: 10.2147/ndt.s176478] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
PURPOSE Antipsychotic drug treatment can potentially lead to adverse events such as extrapyramidal symptoms (EPSs). If these events persist, they lower patient quality of life. The purpose of this report is to present our experience with such a case, as an example to encourage further study. PATIENTS AND METHODS The patient was a 64-year-old male who had been diagnosed with schizophrenia that had been treated with oral antipsychotics for over 40 years. Due to lack of compliance, he was treated with the long-acting injectable antipsychotic, paliperidone palmitate, but developed persistent EPSs after 6 months. He was subsequently treated and monitored in our inpatient facility. RESULTS Antipsychotic treatment was stopped. After 6 weeks, the patient's psychosis had worsened, but his EPSs remained unchanged. Levodopa treatment was then started (up to 400 mg/d), which improved his EPSs, so he was restarted on oral antipsychotic therapy (aripiprazole, 6-18 mg/d). His psychotic symptoms improved over 2 months. The improvements in both psychosis and EPSs remained stable. Dopamine transporter scans revealed moderate dopamine transporter loss in the striatum, and computed tomography revealed no sign of brain abnormalities, suggesting that the patient was susceptible to dopamine reductions. CONCLUSION Paliperidone palmitate can induce EPSs, even if injected only a few times. Although the characteristics of the drug are potential causes, the patient's predisposition to dopamine perturbations can also influence the outcome. Therefore, adequate awareness is required before injection.
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Affiliation(s)
- Ryohei Takada
- Department of Psychiatry, Nara Medical University School of Medicine, Kashihara, Japan,
| | - Kazuhiko Yamamuro
- Department of Psychiatry, Nara Medical University School of Medicine, Kashihara, Japan,
| | - Toshifumi Kishimoto
- Department of Psychiatry, Nara Medical University School of Medicine, Kashihara, Japan,
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15
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Ruiz-Lopez M, Fasano A. Rethinking status dystonicus. Mov Disord 2017; 32:1667-1676. [PMID: 29144565 DOI: 10.1002/mds.27207] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2017] [Revised: 10/01/2017] [Accepted: 10/06/2017] [Indexed: 01/18/2023] Open
Abstract
Status dystonicus is a movement disorder emergency that has been a source of controversy in terms of terminology, phenomenology, and management since it was first described in 1982. Here we argue that the current use of the term status dystonicus falls well short of the precision needed for either clinical or academic use. We performed a critical review on this topic, describing possible pathophysiological mechanisms and areas of uncertainties. This review also addresses the problems derived by the extreme clinical heterogeneity of this condition, as the lack of an objective criterion useful for the definition, or the fact that status dystonicus may present not only in the context of a known dystonic syndrome. We propose a new possible definition that includes not only dystonia but also other hyperkinetic movements in the wide range of movement disorders that can be seen during an episode. The new definition keeps the term status dystonicus and highlights the fact that this is a medical emergency based on the impairment of bulbar and/or respiratory function requiring hospital admission as the principal feature. Furthermore, the new definition should not consider as necessary unspecific features as patient's condition at baseline, the distribution of dystonia, occurrence of systemic symptoms such as fever or laboratory findings. We hope that this proposal will stimulate the debate on this subject among our peers, further developing a clinical and pathophysiological understanding of status dystonicus. © 2017 International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Marta Ruiz-Lopez
- Morton and Gloria Shulman Movement Disorders Centre and the Edmond J. Safra Program in Parkinson's Disease, Toronto Western Hospital, UHN, Division of Neurology, University of Toronto, Toronto, Ontario, Canada
| | - Alfonso Fasano
- Morton and Gloria Shulman Movement Disorders Centre and the Edmond J. Safra Program in Parkinson's Disease, Toronto Western Hospital, UHN, Division of Neurology, University of Toronto, Toronto, Ontario, Canada.,Krembil Research Institute, Toronto, Ontario, Canada
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16
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Jhang KM, Huang JY, Nfor ON, Tung YC, Ku WY, Lee CT, Liaw YP. Extrapyramidal symptoms after exposure to calcium channel blocker-flunarizine or cinnarizine. Eur J Clin Pharmacol 2017; 73:911-916. [PMID: 28386684 PMCID: PMC5486934 DOI: 10.1007/s00228-017-2247-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Accepted: 03/29/2017] [Indexed: 11/03/2022]
Abstract
Purpose Flunarizine (fz) and cinnarizine (cz) have well-known extrapyramidal side effects (EPSEs). The aim of this study was to evaluate the incidence and occurrence time of cz- and fz-related EPSEs. Method Patients who took fz or cz for more than 1 month were identified from the longitudinal health insurance database 2005 and 2010. Excluded were patients with any of the underlying diseases that may cause parkinsonism. Drug-induced EPSEs were defined as the new diagnosis of parkinsonism, dyskinesia, or secondary dystonia during drug use or within 3 months after discontinuing the medication. Age- and sex-matched controls were included in this study. Results Recruited for analysis were individuals who took fz (n = 26,133) and cz (n = 7186). The incidence rates of fz- and cz-induced EPSEs were 21.03 and 10.3 per 10,000 person-months, respectively. The hazard ratios (HRs) of EPSEs among fz and cz subjects were 8.03 (95% CI 6.55–9.84) and 3.41 (95% CI 2.50–4.63) when compared with the control individuals. Both fz and cz patients had a higher cumulative incidence of EPSEs than their control individuals (p < 0.001). Among subjects who took fz, the incidence of EPSEs was higher in the second than first year of drug exposure (45.59 vs 21.03 per 10,000 person-months). Conclusions Fz and cz significantly increased the risk of parkinsonism, dyskinesia, and dystonia. Potential benefits and risks should be weighed when considering long-term use of these drugs especially fz. Electronic supplementary material The online version of this article (doi:10.1007/s00228-017-2247-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Kai-Ming Jhang
- Department of Public Health and Institute of Public Health, Chung Shan Medical University, No. 110, Sec. 1 Jianguo N. Rd., Taichung City, 40201, Taiwan.,Department of Neurology, Lu-Tung Christian Hospital, Changhua, Taiwan
| | - Jing-Yang Huang
- Department of Public Health and Institute of Public Health, Chung Shan Medical University, No. 110, Sec. 1 Jianguo N. Rd., Taichung City, 40201, Taiwan
| | - Oswald Ndi Nfor
- Department of Public Health and Institute of Public Health, Chung Shan Medical University, No. 110, Sec. 1 Jianguo N. Rd., Taichung City, 40201, Taiwan
| | - Yu-Chun Tung
- Department of Pharmacy, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Wen-Yuan Ku
- Department of Public Health and Institute of Public Health, Chung Shan Medical University, No. 110, Sec. 1 Jianguo N. Rd., Taichung City, 40201, Taiwan
| | - Chun-Te Lee
- Department of Psychiatry, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Yung-Po Liaw
- Department of Public Health and Institute of Public Health, Chung Shan Medical University, No. 110, Sec. 1 Jianguo N. Rd., Taichung City, 40201, Taiwan. .,Department of Family and Community Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan.
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17
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Bello EP, Casas-Cordero R, Galiñanes GL, Casey E, Belluscio MA, Rodríguez V, Noaín D, Murer MG, Rubinstein M. Inducible ablation of dopamine D2 receptors in adult mice impairs locomotion, motor skill learning and leads to severe parkinsonism. Mol Psychiatry 2017; 22:595-604. [PMID: 27431292 DOI: 10.1038/mp.2016.105] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2016] [Revised: 04/20/2016] [Accepted: 05/06/2016] [Indexed: 11/09/2022]
Abstract
Motor execution and planning are tightly regulated by dopamine D1 and D2 receptors present in basal ganglia circuits. Although stimulation of D1 receptors is known to enhance motor function, the global effect of D2 receptor (D2R) stimulation or blockade remains highly controversial, with studies showing increasing, decreasing or no changes in motor activity. Moreover, pharmacological and genetic attempts to block or eliminate D2R have led to controversial results that questioned the importance of D2R in motor function. In this study, we generated an inducible Drd2 null-allele mouse strain that circumvented developmental compensations found in constitutive Drd2-/- mice and allowed us to directly evaluate the participation of D2R in spontaneous locomotor activity and motor learning. We have found that loss of D2R during adulthood causes severe motor impairments, including hypolocomotion, deficits in motor coordination, impaired learning of new motor routines and spontaneous catatonia. Moreover, severe motor impairment, resting tremor and abnormal gait and posture, phenotypes reminiscent of Parkinson's disease, were evident when the mutation was induced in aged mice. Altogether, the conditional Drd2 knockout model studied here revealed the overall fundamental contribution of D2R in motor functions and explains some of the side effects elicited by D2R blockers when used in neurological and psychiatric conditions, including schizophrenia, bipolar disorder, Tourette's syndrome, dementia, alcohol-induced delusions and obsessive-compulsive disorder.
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Affiliation(s)
- E P Bello
- Instituto de Investigaciones en Ingeniería Genética y Biología Molecular, Consejo Nacional de Investigaciones Científicas y Técnicas and Facultad de Ciencias Exactas y Naturales, Universidad de Buenos Aires, Buenos Aires, Argentina
| | - R Casas-Cordero
- Instituto de Investigaciones en Ingeniería Genética y Biología Molecular, Consejo Nacional de Investigaciones Científicas y Técnicas and Facultad de Ciencias Exactas y Naturales, Universidad de Buenos Aires, Buenos Aires, Argentina
| | - G L Galiñanes
- Instituto de Fisiología y Biofísica Bernardo Houssay, Consejo Nacional de Investigaciones Científicas y Técnicas, Buenos Aires, Argentina
| | - E Casey
- Instituto de Investigaciones en Ingeniería Genética y Biología Molecular, Consejo Nacional de Investigaciones Científicas y Técnicas and Facultad de Ciencias Exactas y Naturales, Universidad de Buenos Aires, Buenos Aires, Argentina
| | - M A Belluscio
- Instituto de Fisiología y Biofísica Bernardo Houssay, Consejo Nacional de Investigaciones Científicas y Técnicas, Buenos Aires, Argentina
| | - V Rodríguez
- Instituto de Investigaciones en Ingeniería Genética y Biología Molecular, Consejo Nacional de Investigaciones Científicas y Técnicas and Facultad de Ciencias Exactas y Naturales, Universidad de Buenos Aires, Buenos Aires, Argentina
| | - D Noaín
- Instituto de Investigaciones en Ingeniería Genética y Biología Molecular, Consejo Nacional de Investigaciones Científicas y Técnicas and Facultad de Ciencias Exactas y Naturales, Universidad de Buenos Aires, Buenos Aires, Argentina
| | - M G Murer
- Instituto de Fisiología y Biofísica Bernardo Houssay, Consejo Nacional de Investigaciones Científicas y Técnicas, Buenos Aires, Argentina.,Departamento de Fisiología, Facultad de Medicina, Universidad de Buenos Aires, Buenos Aires, Argentina
| | - M Rubinstein
- Instituto de Investigaciones en Ingeniería Genética y Biología Molecular, Consejo Nacional de Investigaciones Científicas y Técnicas and Facultad de Ciencias Exactas y Naturales, Universidad de Buenos Aires, Buenos Aires, Argentina.,Department of Molecular and Integrative Physiology, University of Michigan, Ann Arbor, MI, USA
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18
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19
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Greenbaum L, Lerer B. Pharmacogenetics of antipsychotic-induced movement disorders as a resource for better understanding Parkinson's disease modifier genes. Front Neurol 2015; 6:27. [PMID: 25750634 PMCID: PMC4335175 DOI: 10.3389/fneur.2015.00027] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2014] [Accepted: 01/30/2015] [Indexed: 12/05/2022] Open
Abstract
Antipsychotic-induced movement disorders are major side effects of antipsychotic drugs among schizophrenia patients, and include antipsychotic-induced parkinsonism (AIP) and tardive dyskinesia (TD). Substantial pharmacogenetic work has been done in this field, and several susceptibility variants have been suggested. In this paper, the genetics of antipsychotic-induced movement disorders is considered in a broader context. We hypothesize that genetic variants that are risk factors for AIP and TD may provide insights into the pathophysiology of motor symptoms in Parkinson’s disease (PD). Since loss of dopaminergic stimulation (albeit pharmacological in AIP and degenerative in PD) is shared by the two clinical entities, genes associated with susceptibility to AIP may be modifier genes that influence clinical expression of PD motor sub-phenotypes, such as age at onset, disease severity, or rate of progression. This is due to their possible functional influence on compensatory mechanisms for striatal dopamine loss. Better compensatory potential might be beneficial at the early and later stages of the PD course. AIP vulnerability variants could also be related to latent impairment in the nigrostriatal pathway, affecting its functionality, and leading to subclinical dopaminergic deficits in the striatum. Susceptibility of PD patients to early development of l-DOPA induced dyskinesia (LID) is an additional relevant sub-phenotype. LID might share a common genetic background with TD, with which it shares clinical features. Genetic risk variants may predispose to both phenotypes, exerting a pleiotropic effect. According to this hypothesis, elucidating the genetics of antipsychotic-induced movement disorders may advance our understanding of multiple aspects of PD and it clinical course, rendering this a potentially rewarding field of study.
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Affiliation(s)
- Lior Greenbaum
- Department of Neurology, Sheba Medical Center at Tel Hashomer , Ramat Gan , Israel ; The Joseph Sagol Neuroscience Center, Sheba Medical Center at Tel Hashomer , Ramat Gan , Israel
| | - Bernard Lerer
- Biological Psychiatry Laboratory, Department of Psychiatry, Hadassah - Hebrew University Medical Center , Jerusalem , Israel
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20
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Ba F, Martin WW. Dopamine transporter imaging as a diagnostic tool for parkinsonism and related disorders in clinical practice. Parkinsonism Relat Disord 2015; 21:87-94. [PMID: 25487733 DOI: 10.1016/j.parkreldis.2014.11.007] [Citation(s) in RCA: 107] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Revised: 11/12/2014] [Accepted: 11/12/2014] [Indexed: 01/22/2023]
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21
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Vogt I, Prinz J, Campillos M. Molecularly and clinically related drugs and diseases are enriched in phenotypically similar drug-disease pairs. Genome Med 2014; 6:52. [PMID: 25276232 PMCID: PMC4165361 DOI: 10.1186/s13073-014-0052-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2014] [Accepted: 07/07/2014] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND The incomplete understanding of disease causes and drug mechanisms of action often leads to ineffective drug therapies or side effects. Therefore, new approaches are needed to improve treatment decisions and to elucidate molecular mechanisms underlying pathologies and unwanted drug effects. METHODS We present here the first analysis of phenotypically related drug-disease pairs. The phenotypic similarity between 4,869 human diseases and 1,667 drugs was evaluated using an ontology-based semantic similarity approach to compare disease symptoms with drug side effects. We assessed and visualized the enrichment over random of clinical and molecular relationships among drug-disease pairs that share phenotypes using lift plots. To determine the associations between drug and disease classes enriched among phenotypically related pairs we employed a network-based approach combined with Fisher's exact test. RESULTS We observed that molecularly and clinically related (for example, indication or contraindication) drugs and diseases are likely to share phenotypes. An analysis of the relations between drug mechanisms of action (MoAs) and disease classes among highly similar pairs revealed known and suspected MoA-disease relationships. Interestingly, we found that contraindications associated with high phenotypic similarity often involve diseases that have been reported as side effects of the drug, probably due to common mechanisms. Based on this, we propose a list of 752 precautions or potential contraindications for 486 drugs. CONCLUSIONS Phenotypic similarity between drugs and diseases facilitates the proposal of contraindications and the mechanistic understanding of diseases and drug side effects.
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Affiliation(s)
- Ingo Vogt
- />Institute of Bioinformatics and Systems Biology, Helmholtz Zentrum München, 85764 Neuherberg, Germany
- />German Center for Diabetes Research, 85764 Neuherberg, Germany
| | - Jeanette Prinz
- />Institute of Bioinformatics and Systems Biology, Helmholtz Zentrum München, 85764 Neuherberg, Germany
- />German Center for Diabetes Research, 85764 Neuherberg, Germany
| | - Mónica Campillos
- />Institute of Bioinformatics and Systems Biology, Helmholtz Zentrum München, 85764 Neuherberg, Germany
- />German Center for Diabetes Research, 85764 Neuherberg, Germany
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Morley JF, Pawlowski SM, Kesari A, Maina I, Pantelyat A, Duda JE. Motor and non-motor features of Parkinson's disease that predict persistent drug-induced Parkinsonism. Parkinsonism Relat Disord 2014; 20:738-42. [DOI: 10.1016/j.parkreldis.2014.03.024] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Revised: 03/12/2014] [Accepted: 03/24/2014] [Indexed: 01/08/2023]
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Imaging of the dopamine transporter predicts pattern of disease progression and response to levodopa in patients with schizophrenia and parkinsonism: a 2-year follow-up multicenter study. Schizophr Res 2014; 152:344-9. [PMID: 24369987 DOI: 10.1016/j.schres.2013.11.028] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2013] [Revised: 11/17/2013] [Accepted: 11/18/2013] [Indexed: 12/21/2022]
Abstract
Similarly to subjects with degenerative parkinsonism, (123)I-FP-CIT SPECT has been reported either normal or abnormal in patients with drug-induced parkinsonism (DIP), challenging the notion that parkinsonism might be entirely due to post-synaptic D2-receptors blockade by antipsychotic drugs. In a previous multicenter cross-sectional study conducted on a large sample of patients with schizophrenia, we identified 97 patients who developed parkinsonism with a similar bi-modal distribution of DAT-SPECT. In this longitudinal study, we reported clinical and imaging features associated with progression of motor disability over 2-year follow-up in 60 out of those 97 patients with schizophrenia and parkinsonism who underwent (123)I-FP-CIT SPECT at baseline evaluation (normal SPECT=33; abnormal SPECT=27). As second end-point, chronic response to levodopa over a 3-month period was tested in a subgroup of subjects. Motor Unified Parkinson's Disease Rating Scale (UPDRS) at follow-up significantly increased in patients with abnormal SPECT. Specifically, a 6-point worsening was demonstrated in 18.5% of the subjects with abnormal SPECT and in none of the subjects with normal SPECT. Levodopa treatment improved motor UPDRS only in the group with abnormal SPECT. After adjustment for possible confounders, linear regression analysis demonstrated that abnormal SPECT findings at baseline were the only predictor of motor disability progression and of better outcome of levodopa treatment. Our results support the notion that a degenerative disease might underlie parkinsonism in a minority of schizophrenic patients chronically exposed to antipsychotics. Functional imaging of the dopamine transporter can be helpful to select this patient sub-group that might benefit from levodopa therapy.
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Lohr JB, Liu L, Caligiuri MP, Kash TP, May TA, Murphy JD, Ancoli-Israel S. Modafinil improves antipsychotic-induced parkinsonism but not excessive daytime sleepiness, psychiatric symptoms or cognition in schizophrenia and schizoaffective disorder: a randomized, double-blind, placebo-controlled study. Schizophr Res 2013; 150:289-96. [PMID: 23938173 DOI: 10.1016/j.schres.2013.07.039] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2013] [Revised: 07/16/2013] [Accepted: 07/19/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To examine the efficacy and safety of modafinil on parkinsonism and excessive daytime sleepiness (EDS), as well as on negative symptoms and cognitive abilities in patients with schizophrenia or schizoaffective disorder (DSM-IV criteria) in a randomized double-blind placebo-controlled 8-week study. METHODS Twenty-four male patients, who were aged 20-63 years and on stable dose of second generation antipsychotic medications and with a negative symptom score of ≥ 20 on the Positive and Negative Syndrome Scale (PANSS), were randomized into either the modafinil (n=12) or placebo (n=12) group. The modafinil group received flexible does of modafinil 50-200mg/day. Primary measurements were the Simpson-Angus Scale (SAS) for extrapyramidal side effects (EPS), the Epworth Sleepiness Scale (ESS), the PANSS and a neuropsychological (NP) test battery. Data were collected on Days 0, 14, 28, 42 and 56 for rating scales, and on Days 0, 28 and 56 for NP tests. RESULTS Mixed model analyses showed a significant group-x-time interaction for total SAS scores (P<0.006), with scores decreasing in the modafinil group but remaining the same in the placebo group. There were no significant group-x-time interactions for scores of ESS (total), PANSS (total, positive and negative), and NP tests (composite and domains) (all P's>0.5). No significant adverse events were observed. CONCLUSION The data suggest that modafinil was a safe adjunctive treatment which improved parkinsonian symptoms and signs in patients with schizophrenia or schizoaffective disorder. Further studies in larger samples and with longer study time are needed to test/confirm the beneficial effects of modafinil on motor function.
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Affiliation(s)
- James B Lohr
- Department of Psychiatry, University of California, San Diego (UCSD), La Jolla, CA, USA; Psychiatry Service, VA San Diego Healthcare System, San Diego, CA, USA; VA Center of Excellence for Stress and Mental Health, San Diego, CA, USA.
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Tinazzi M, Cipriani A, Matinella A, Cannas A, Solla P, Nicoletti A, Zappia M, Morgante L, Morgante F, Pacchetti C, Sciarretta M, Dallocchio C, Rossi S, Malentacchi M, Ceravolo R, Frosini D, Sestini S, Bovi T, Barbui C. [¹²³I]FP-CIT single photon emission computed tomography findings in drug-induced Parkinsonism. Schizophr Res 2012; 139:40-5. [PMID: 22727453 DOI: 10.1016/j.schres.2012.06.003] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2011] [Revised: 05/08/2012] [Accepted: 06/02/2012] [Indexed: 10/28/2022]
Abstract
Drug-induced parkinsonism (DIP) in patients treated with antipsychotic drugs is considered a form of post-synaptic parkinsonism, caused by D2-receptor blockade. Recent studies, however, carried out on small and heterogeneous patient samples, have shown that DIP may be associated with [(123)I]FP-CIT single photon emission computed tomography (SPECT) abnormalities, which are markers of dopamine nigrostriatal terminal defect. In the present study, outpatients fulfilling the DSM-IV criteria for schizophrenia and treated with antipsychotics for at least 6 months, were enrolled in order to estimate the prevalence of DIP and, among patients with DIP, the prevalence of [(123)I]FP-CIT SPECT abnormalities. Socio-demographic and clinical variables associated with the presence of DIP and SPECT abnormalities were also assessed. DIP was diagnosed in 149 out of 448 patients with schizophrenia (33%). Age, use of long-acting antipsychotics and a positive family history of parkinsonism were the only demographic variables significantly associated with the development of DIP. Neuroimaging abnormalities were found in 41 of 97 patients who agreed to undergo [(123)I]FP-CIT SPECT (42%). Only age differentiated this group of patients from those with normal imaging. These preliminary findings suggest that D2-receptor blockade may coexist with a dopamine nigrostriatal terminal defect, as assessed by [(123)I]FP-CIT SPECT abnormalities, in a relevant proportion of DIP patients. Longitudinal studies should be designed with the aim of improving our understanding of the mechanisms of pre-synaptic abnormalities in DIP patients and identifying specific treatment strategies.
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Affiliation(s)
- Michele Tinazzi
- Department of Neurological, Neuropsychological, Morphological and Motor Sciences, University of Verona, Italy
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Shin HW, Chung SJ. Drug-induced parkinsonism. J Clin Neurol 2012; 8:15-21. [PMID: 22523509 PMCID: PMC3325428 DOI: 10.3988/jcn.2012.8.1.15] [Citation(s) in RCA: 194] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2011] [Revised: 06/28/2011] [Accepted: 06/28/2011] [Indexed: 11/17/2022] Open
Abstract
Drug-induced parkinsonism (DIP) is the second-most-common etiology of parkinsonism in the elderly after Parkinson's disease (PD). Many patients with DIP may be misdiagnosed with PD because the clinical features of these two conditions are indistinguishable. Moreover, neurological deficits in patients with DIP may be severe enough to affect daily activities and may persist for long periods of time after the cessation of drug taking. In addition to typical antipsychotics, DIP may be caused by gastrointestinal prokinetics, calcium channel blockers, atypical antipsychotics, and antiepileptic drugs. The clinical manifestations of DIP are classically described as bilateral and symmetric parkinsonism without tremor at rest. However, about half of DIP patients show asymmetrical parkinsonism and tremor at rest, making it difficult to differentiate DIP from PD. The pathophysiology of DIP is related to drug-induced changes in the basal ganglia motor circuit secondary to dopaminergic receptor blockade. Since these effects are limited to postsynaptic dopaminergic receptors, it is expected that presynaptic dopaminergic neurons in the striatum will be intact. Dopamine transporter (DAT) imaging is useful for diagnosing presynaptic parkinsonism. DAT uptake in the striatum is significantly decreased even in the early stage of PD, and this characteristic may help in differentiating PD from DIP. DIP may have a significant and longstanding effect on patients' daily lives, and so physicians should be cautious when prescribing dopaminergic receptor blockers and should monitor patients' neurological signs, especially for parkinsonism and other movement disorders.
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Affiliation(s)
- Hae-Won Shin
- Department of Neurology, Chung-Ang University College of Medicine, Seoul, Korea
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Abstract
BACKGROUND Antipsychotics are effective in treating the symptoms of schizophrenia, but they may induce adverse effects, some of which-those that impact negatively on physical appearance-have not been sufficiently discussed in the psychiatric literature. AIM Through a narrative review, to catalog antipsychotic side effects that interfere with physical attractiveness and to suggest ways of addressing them. METHOD PubMed databases were searched for information on the association between "antipsychotic side effects" and "attractiveness" using those two search phrases plus the following terms: "weight," "teeth," "skin," "hair," "eyes," "gait," "voice," "odor." Data from relevant qualitative and quantitative articles were considered, contextualized, and summarized. RESULTS Antipsychotics, as a group, increase weight and may lead to dry mouth and bad breath, cataracts, hirsutism, acne, and voice changes; they may disturb symmetry of gait and heighten the risk for tics and spasms and incontinence, potentially undermining a person's attractiveness. CONCLUSIONS Clinicians need to be aware of the impact of therapeutic drugs on appearance and how important this issue is to patients. Early in treatment, they need to plan preventive and therapeutic strategies.
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Ugoya SO, Agaba EI, Daniyam CA. Parkinsonism caused by adverse drug reactions: a case series. J Med Case Rep 2011; 5:105. [PMID: 21410947 PMCID: PMC3068104 DOI: 10.1186/1752-1947-5-105] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2010] [Accepted: 03/16/2011] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Parkinsonism puts a high direct cost burden on both patient and caregiver. Several reports of drug-induced parkinsonism have been published, but to the best of our knowledge, there has not been any report of quinine or halothane inducing parkinsonism. CASE PRESENTATION We describe two cases of parkinsonism possibly caused by adverse drug reaction to quinine in a 29-year-old black Nigerian woman and to halothane in a 36-year-old black Hausa (Nigerian) man who received it as general anaesthesia for appendicectomy in our teaching hospital. CONCLUSION These are two unusual cases of parkinsonism caused by adverse drug reactions to high-dose quinine and to halothane as general anaesthesia. We consider that these two cases are important in bringing this potential side-effect to the attention of both pharmacologists and primary care physicians as these are two of the most commonly used medications in our clinics. We conclude that parkinsonism should be included among the adverse drug reactions to high-dose quinine and halothane general anaesthetic.
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Affiliation(s)
- Solomon O Ugoya
- Department of Medicine, Jos University Teaching Hospital, PMB 2076, Jos, Nigeria.
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Abstract
BACKGROUND Levodopa-responsive Parkinsonism is a rare complication of subarachnoid hemorrhage and no cases have been reported to occur in the absence of hydrocephalus. METHODS Case report. RESULTS We describe a 42-year-old woman who developed progressive severe Parkinsonism in the second week after aneurysmal subarachnoid hemorrhage. No hydrocephalus was present. Neuroimaging revealed striking abnormalities of the midbrain in the region of the substantia nigra. She was ultimately treated with high dose levodopa/carbidopa with a dramatic response. CONCLUSIONS This case suggests that Parkinsonism may occur as a delayed complication of subarachnoid hemorrhage, and that in these patients, a trial of levodopa-carbidopa may be warranted.
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Affiliation(s)
- Jeremy D Fields
- Neurosciences Critical Care and Interventional Neuroradiology, Oregon Health & Science University, Portland, OR, USA.
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Bovi T, Antonini A, Ottaviani S, Antonioli A, Cecchini MP, Di Francesco V, Bassetto MA, Zamboni M, Fiaschi A, Moretto G, Sbarbati A, Tinazzi M, Osculati F. The status of olfactory function and the striatal dopaminergic system in drug-induced parkinsonism. J Neurol 2010; 257:1882-9. [DOI: 10.1007/s00415-010-5631-3] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2010] [Revised: 06/02/2010] [Accepted: 06/11/2010] [Indexed: 12/22/2022]
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Current awareness: Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2009. [DOI: 10.1002/pds.1653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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