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Liotta M, Bell H, Vu AT, Stillman M. Drug-Induced Parkinsonism: Too Many Cooks in the Kitchen. Cureus 2023; 15:e44896. [PMID: 37814773 PMCID: PMC10560449 DOI: 10.7759/cureus.44896] [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] [Accepted: 09/07/2023] [Indexed: 10/11/2023] Open
Abstract
Drug-induced parkinsonism (DIP) is a condition characterized by the development of parkinsonian symptoms as a result of medication use. It is often misdiagnosed and can be challenging to differentiate from Parkinson's disease (PD). In this case presentation, we describe the clinical course of a 64-year-old male who presented with parkinsonian symptoms while using atypical antipsychotics, which was originally misdiagnosed as PD. The case highlights the importance of recognizing the potential iatrogenic effects of medications with antidopaminergic properties, such as antipsychotics and antiepileptic drugs, which are common culprits in causing DIP. We discuss DIP management, long-term impacts, and differentiating DIP from PD through clinical findings and imaging, emphasizing the utility of the (123)I-ioflupane single-photon emission computerized tomography (SPECT) scan in aiding diagnosis. This case serves as a reminder to healthcare providers to remain vigilant in monitoring patients for adverse effects, polypharmacy, and harmful medication interactions.
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Affiliation(s)
- Mark Liotta
- Internal Medicine, Thomas Jefferson University Hospital, Philadelphia, USA
| | - Harrison Bell
- Internal Medicine, Thomas Jefferson University Hospital, Philadelphia, USA
| | - Anh-Thu Vu
- Neurology, Thomas Jefferson University Hospital, Philadelphia, USA
| | - Michael Stillman
- Internal Medicine, Thomas Jefferson University Hospital, Philadelphia, USA
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2
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Sekiguchi K, Mashiko T, Koide R, Kawai K, Fujimoto S, Tanaka R. A Case of Long-Term Exposure to Valproic Acid Mimicking Tremor-Dominant Parkinson's Disease. Tremor Other Hyperkinet Mov (N Y) 2023; 13:17. [PMID: 37214540 PMCID: PMC10198224 DOI: 10.5334/tohm.755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 04/20/2023] [Indexed: 05/24/2023] Open
Abstract
Background Valproic acid is associated with increased risks of tremor and parkinsonism. Case Report A 67-year-old man with a diagnosis of epilepsy who had been treated with valproic acid (VPA) for 32 years noticed right-dominant upper-limb resting tremor accompanied by mild rigidity and bradykinesia. He was initially diagnosed with tremor-dominant Parkinson's disease (TDPD), but dopamine transporter single-photon emission computed tomography demonstrated no nigrostriatal degeneration. At 3 months after discontinuing VPA, his symptoms dramatically improved. Discussion VPA-induced tremor usually consists of postural or kinetic tremor without asymmetry. Our case indicated that careful evaluation is needed, even in cases of asymmetrical resting tremor and mild parkinsonism resembling TDPD after long term exposure to VPA. Highlights We report an atypical case of valproic acid-induced tremor and parkinsonism that mimics tremor-dominant Parkinson's disease. Physicians should not exclude the possible relation to valproic acid in patients presenting unilateral resting tremor and parkinsonism even in the absence of long-term side effects.
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Affiliation(s)
- Kazumasa Sekiguchi
- Division of Neurology, Department of Medicine, Jichi Medical University, Tochigi, Japan
| | - Toshihiro Mashiko
- Department of Neurosurgery, Jichi Medical University, Tochigi, Japan
| | - Reiji Koide
- Division of Neurology, Department of Medicine, Jichi Medical University, Tochigi, Japan
| | - Kensuke Kawai
- Department of Neurosurgery, Jichi Medical University, Tochigi, Japan
| | - Shigeru Fujimoto
- Division of Neurology, Department of Medicine, Jichi Medical University, Tochigi, Japan
| | - Ryota Tanaka
- Division of Neurology, Department of Medicine, Jichi Medical University, Tochigi, Japan
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3
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Weng J, Zhang L, Yu W, Zhao N, Zhu B, Ye C, Zhang Z, Ma C, Li Y, Yu Y, Li H. Risk factors, clinical correlates, and social functions of Chinese schizophrenia patients with drug-induced parkinsonism: A cross-sectional analysis of a multicenter, observational, real-world, prospective cohort study. Front Pharmacol 2023; 14:1077607. [PMID: 36937864 PMCID: PMC10020528 DOI: 10.3389/fphar.2023.1077607] [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: 10/23/2022] [Accepted: 02/15/2023] [Indexed: 03/06/2023] Open
Abstract
Background: Drug-induced parkinsonism (DIP) is the most prevalent neurological side effect of antipsychotics in the Chinese population. Early prevention, recognition, and treatment of DIP are important for the improvement of treatment outcomes and medication adherence of schizophrenia patients. However, the risk factors of DIP and the impact on the clinical syndromes of schizophrenia remain unknown. Aim: The goal of this study was to explore the risk factors, clinical correlates, and social functions of DIP in Chinese schizophrenia patients. Methods: A cross-sectional analysis of a multicenter, observational, real-world, prospective cohort study of the Chinese schizophrenia population with a baseline assessment was conducted from the year 2012 to 2018. Participants were recruited from four mental health centers in Shanghai and totaled 969 subjects. Sociodemographic data, drug treatment, and clinical variables were compared between the DIP group and the non-DIP group. Variables that correlated with the induction of DIP, and with p≤ 0.1, were included in the binary logistic model for analyzing the risk factors of DIP. First generation antipsychotics (FGA)/second generation antipsychotics (SGA) model and high and low/medium D2 receptor antipsychotics were analyzed respectively to control the bias of co-linearity. All risk factors derived from the a forementioned models and clinical variables with p≤ 0.1 were included in the multivariate analysis of clinical correlates and social function of DIP patients. The Positive and Negative Syndrome Scale (PANSS) model and the personal and social performance (PSP) model were analyzed separately to control for co-linearity bias. Results: Age (OR = 1.03, p< 0.001), high D2 receptor antagonist antipsychotic dose (OR = 1.08, p = 0.032), and valproate dose (OR = 1.01, p = 0.001) were the risk factors of DIP. FGA doses were not a significant contributor to the induction of DIP. Psychiatric symptoms, including more severe negative symptoms (OR = 1.09, p< 0.001), lower cognition status (OR = 1.08, p = 0.033), and lower excited symptoms (OR = 0.91, p = 0.002), were significantly correlated with DIP induction. Social dysfunction, including reduction in socially useful activities (OR = 1.27, p = 0.004), lower self-care capabilities (OR = 1.53, p< 0.001), and milder disturbing and aggressive behavior (OR = 0.65, p< 0.001), were significantly correlated with induction of DIP. Valproate dose was significantly correlated with social dysfunction (OR = 1.01, p = 0.001) and psychiatric symptoms (OR = 1.01, p = 0.004) of DIP patients. Age may be a profound factor that affects not only the induction of DIP but also the severity of psychiatric symptoms (OR = 1.02, p< 0.001) and social functions (OR = 1.02, p< 0.001) of schizophrenia patients with DIP. Conclusion: Age, high D2 receptor antagonist antipsychotic dose, and valproate dose are risk factors for DIP, and DIP is significantly correlated with psychiatric symptoms and social performance of Chinese schizophrenia patients. The rational application or discontinuation of valproate is necessary. Old age is related to psychotic symptoms and social adaption in Chinese schizophrenic patients, and early intervention and treatment of DIP can improve the prognosis and social performance of schizophrenia patients. Clinical Trial Registration: Identifier: NCT02640911.
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Affiliation(s)
- Jiajun Weng
- Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Zhongshan Hospital, Shanghai, China
| | - Lei Zhang
- Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wenjuan Yu
- Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Nan Zhao
- Shanghai Pudong District Mental Health Center, Shanghai, China
| | - Binggen Zhu
- Shanghai Pudong District Mental Health Center, Shanghai, China
| | - Chengyu Ye
- Shanghai Zhongshan Hospital, Shanghai, China
- Shanghai Jiading District Mental Health Center, Shanghai, China
| | - Zhanxing Zhang
- Shanghai Clinical Research Center for Mental Health, Shanghai, China
| | - Changlin Ma
- Shanghai Jiading District Mental Health Center, Shanghai, China
| | - Yan Li
- Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yiming Yu
- Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- *Correspondence: Yiming Yu, ; Huafang Li,
| | - Huafang Li
- Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Clinical Research Center for Mental Health, Shanghai, China
- *Correspondence: Yiming Yu, ; Huafang Li,
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4
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De Biase A, Paparella G, Angelini L, Cannavacciuolo A, Colella D, Cerulli Irelli E, Giallonardo AT, Di Bonaventura C, Berardelli A, Bologna M. TREMOR AND MOVEMENT SLOWNESS ARE TWO UNRELATED SIDE EFFECTS INDUCED BY VALPROATE INTAKE. Mov Disord Clin Pract 2022; 9:1062-1073. [DOI: 10.1002/mdc3.13560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 07/29/2022] [Accepted: 08/13/2022] [Indexed: 11/11/2022] Open
Affiliation(s)
| | | | - Luca Angelini
- Department of Human Neurosciences Sapienza University of Rome Italy
| | | | - Donato Colella
- Department of Human Neurosciences Sapienza University of Rome Italy
| | | | | | | | - Alfredo Berardelli
- Department of Human Neurosciences Sapienza University of Rome Italy
- IRCCS Neuromed Pozzilli (IS) Italy
| | - Matteo Bologna
- Department of Human Neurosciences Sapienza University of Rome Italy
- IRCCS Neuromed Pozzilli (IS) Italy
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5
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Zhou DJ, Pavuluri S, Snehal I, Schmidt CM, Situ-Kcomt M, Taraschenko O. Movement disorders associated with antiseizure medications: A systematic review. Epilepsy Behav 2022; 131:108693. [PMID: 35483204 PMCID: PMC9596228 DOI: 10.1016/j.yebeh.2022.108693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 03/14/2022] [Accepted: 03/31/2022] [Indexed: 11/19/2022]
Abstract
New-onset movement disorders have been frequently reported in association with the use of antiseizure medications (ASMs). The frequency of specific motor manifestations and the spectrum of their semiology for various ASMs have not been well characterized. We carried out a systematic review of literature and conducted a search on CINAHL, Cochrane Library, EMBASE, MEDLINE, PsycINFO, and Scopus from inception to April 2021. We compiled the data for all currently available ASMs using the conventional terminology of movement disorders. Among 5123 manuscripts identified by the search, 437 met the inclusion criteria. The largest number of reports of abnormal movements were in association with phenobarbital, valproic acid, lacosamide, and perampanel, and predominantly included tremor and ataxia. The majority of attempted interventions for all agents were discontinuation of the offending drug or dose reduction which led to the resolution of symptoms in most patients. Familiarity with the movement disorder phenomenology previously encountered in relation with specific ASMs facilitates early recognition of adverse effects and timely institution of targeted interventions.
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Affiliation(s)
- Daniel J Zhou
- Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, NE, United States
| | - Spriha Pavuluri
- Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, NE, United States
| | - Isha Snehal
- Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, NE, United States
| | - Cynthia M Schmidt
- Leon S. McGoogan Health Sciences Library, University of Nebraska Medical Center, Omaha, NE, United States
| | - Miguel Situ-Kcomt
- Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, NE, United States
| | - Olga Taraschenko
- Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, NE, United States.
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6
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Baizabal-Carvallo JF, Morgan JC. Drug-induced tremor, clinical features, diagnostic approach and management. J Neurol Sci 2022; 435:120192. [DOI: 10.1016/j.jns.2022.120192] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 02/06/2022] [Accepted: 02/17/2022] [Indexed: 11/30/2022]
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7
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Bonam SR, Tranchant C, Muller S. Autophagy-Lysosomal Pathway as Potential Therapeutic Target in Parkinson's Disease. Cells 2021; 10:3547. [PMID: 34944054 PMCID: PMC8700067 DOI: 10.3390/cells10123547] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 12/13/2021] [Accepted: 12/13/2021] [Indexed: 01/18/2023] Open
Abstract
Cellular quality control systems have gained much attention in recent decades. Among these, autophagy is a natural self-preservation mechanism that continuously eliminates toxic cellular components and acts as an anti-ageing process. It is vital for cell survival and to preserve homeostasis. Several cell-type-dependent canonical or non-canonical autophagy pathways have been reported showing varying degrees of selectivity with regard to the substrates targeted. Here, we provide an updated review of the autophagy machinery and discuss the role of various forms of autophagy in neurodegenerative diseases, with a particular focus on Parkinson's disease. We describe recent findings that have led to the proposal of therapeutic strategies targeting autophagy to alter the course of Parkinson's disease progression.
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Affiliation(s)
- Srinivasa Reddy Bonam
- Institut National de la Santé et de la Recherche Médicale, Centre de Recherche des Cordeliers, Equipe-Immunopathologie et Immunointervention Thérapeutique, Sorbonne Université, Université de Paris, 75006 Paris, France
| | - Christine Tranchant
- Service de Neurologie, Hôpitaux Universitaires de Strasbourg, 67000 Strasbourg, France;
- Institut de Génétique et de Biologie Moléculaire et Cellulaire (IGBMC), INSERM-U964/CNRS-UMR7104/Université de Strasbourg, 67400 Illkirch, France
- Fédération de Médecine Translationnelle de Strasbourg (FMTS), Université de Strasbourg, 67000 Strasbourg, France
| | - Sylviane Muller
- Fédération de Médecine Translationnelle de Strasbourg (FMTS), Université de Strasbourg, 67000 Strasbourg, France
- CNRS and Strasbourg University, Unit Biotechnology and Cell Signaling/Strasbourg Drug Discovery and Development Institute (IMS), 67000 Strasbourg, France
- University of Strasbourg Institute for Advanced Study (USIAS), 67000 Strasbourg, France
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8
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Rissardo JP, Caprara ALF, Durante Í. Valproate-associated Movement Disorder: A Literature Review. Prague Med Rep 2021; 122:140-180. [PMID: 34606429 DOI: 10.14712/23362936.2021.14] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
Valproate (VPA) was first synthesized in 1882, but it was only in the early 1960s that its anticonvulsant properties were discovered. The aim of this literature review is to evaluate the clinical epidemiological profile, pathological mechanisms, and management of VPA-associated movement disorder (MD). Relevant reports in six databases were identified and assessed by two reviewers without language restriction. A total of 138 reports containing 362 cases of subjects who developed a MD secondary to VPA were reported. The MD identified were parkinsonism (PKN) (252), myoclonus (MCL) (54), dystonia (DTN) (17), dyskinesia (DKN) (16), stutters (4), tics (3), akathisia (AKT) (1). In the not clearly defined group, 15 extrapyramidal symptoms, 3 AKT, 2 DTN, 1 rigidity, 1 unstable gait were assessed. The mean and median age was 55.8 (SD: 16.58) and 61 years (range: 4-87 years). The most common VPA-indication was epilepsy, and 51.36% were males. The mean and median time from the VPA start to the MD onset was 32.75 (SD: 30.05) and 21.15 months (range: 1 day - 20 years). The mean and median time from the VPA withdrawal until the MD recovery was 2.89 (SD: 2.79) and 3 months (1 day - 12 months). The most common management was drug withdrawal. A complete recovery was obtained in 80.61%. VPA-associated MD was extensively reported in the literature. PKN was the most well-described. Future studies need to clearly report the clinical history of the patient, considering the full investigation of other adverse events during their entire life.
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Affiliation(s)
| | | | - Ícaro Durante
- Department of Medicine, Federal University of Fronteira Sul, Passo Fundo, Brazil
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Valproic acid-induced encephalopathy: A review of clinical features, risk factors, diagnosis, and treatment. Epilepsy Behav 2021; 120:107967. [PMID: 34004407 DOI: 10.1016/j.yebeh.2021.107967] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 04/02/2021] [Accepted: 04/02/2021] [Indexed: 11/23/2022]
Abstract
Valproic acid (VPA), or sodium valproate, is a commonly used medication for seizure disorders, migraines, and mental illness. Although VPA is relatively safe, it still has several adverse effects; among these, VPA-induced encephalopathy is the most serious. Valproic acid-induced encephalopathy mainly manifests as acute or subacute encephalopathy and has been associated with hyperammonemia, L-carnitine deficiency, and urea cycle enzyme dysfunction. Delayed identification of VPA-induced encephalopathy could be potentially fatal. Here, we perform an extensive review of relevant literature pertaining to VPA-induced encephalopathy, including its epidemiology, clinical features, possible pathophysiology, risk factors, diagnosis, and treatment.
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10
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Valproate-induced rest tremor and parkinsonism. Acta Neurol Belg 2021; 121:515-519. [PMID: 31721077 DOI: 10.1007/s13760-019-01239-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 11/06/2019] [Indexed: 11/08/2022]
Abstract
Tremor and parkinsonism are recognized side effects of valproate; however, the relationship between rest tremor and other signs of parkinsonism has not been addressed in patients taking valproate. We studied a cohort of 125 consecutive patients treated with valproate due to epilepsy or migraine, evaluated with the Fahn-Tolosa-Marin Tremor Rating Scale (FTM-TRS). A total of 14 (11.2%) patients had rest tremor (bilateral n = 10, unilateral n = 4). Patients with rest tremor had significant higher scores in the FTM-TRS (P < 0.001), but only one was diagnosed with parkinsonism. Patients may have valproate-induced parkinsonism or exacerbated motor features of Parkinson's disease by valproate. The frequency of parkinsonism was 1.6% in this cohort and of 3% in the pooled data of 717 patients from previous reports. Rest tremor is observed in 11.2% of patients treated with valproate and is related to the burden of valproate-induced tremor, rather than the presence of parkinsonism.
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FTLD Treatment: Current Practice and Future Possibilities. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2021; 1281:297-310. [PMID: 33433882 DOI: 10.1007/978-3-030-51140-1_18] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/21/2023]
Abstract
While behavioral variant frontotemporal dementia (bvFTD) and primary progressive aphasia (PPA) remain unrelenting and universally fatal conditions, there is a framework for supportive treatment in patients diagnosed with these frontotemporal dementia (FTD) syndromes and the larger spectrum of clinical syndromes associated with frontotemporal lobar degeneration (FTLD) pathology on autopsy. A managing physician has an important role in weighing therapeutic options, organizing caregiver support, and framing long-term expectations for patients and caregivers. Additionally, a dedicated neurologist may assist patients and caregivers in navigating a growing range of FTD research, including exciting opportunities in clinical therapeutic trials. This chapter will review current therapeutic options for patients with bvFTD and PPA and detail the landscape of potential new disease-modifying therapies targeting the pathophysiology or FTLD.
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Muralidharan A, Rahman J, Banerjee D, Hakim Mohammed AR, Malik BH. Parkinsonism: A Rare Adverse Effect of Valproic Acid. Cureus 2020; 12:e8782. [PMID: 32724733 PMCID: PMC7381881 DOI: 10.7759/cureus.8782] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 06/23/2020] [Indexed: 11/05/2022] Open
Abstract
Valproic acid (VPA) is an anti-epileptic drug (AED) used as a first-choice agent for most forms of epilepsy. It is used in the treatment of manic episodes, bipolar disorder, migraine prevention, and impulse control. Hence it is one of the most commonly prescribed drugs by physicians nowadays. VPA acts by increasing gama amino butyric acid (GABA) levels, and also reduces neuronal activation by blocking voltage-gated sodium, potassium, and calcium channels. VPA has various adverse effects like thrombocytopenia, hyperammonemia, teratogenicity causing spina bifida in newborns when exposed in utero. The focus of this review is to research one such easily overlooked adverse effect of VPA, which is VPA-induced Parkinsonism. We carried out a review of literature and gathered all comprehensive peer-reviewed articles from PubMed. The data for this research were collected ethically and legally after a thorough examination of the literature. Data obtained from the studies have suggested that Parkinsonism is an adverse effect of VPA. Chronic usage of VPA causes Parkinsonism. It occurs equally in males and females, more common in older people usually above the age of 55 years and not dose-dependent. According to the data obtained, all patients who developed Parkinsonism had serum levels in the therapeutic range (50-100 mcg/mL). Thus the chronic intake of maintenance dose of VPA seems to be the leading cause. The symptoms usually improve over a few weeks and fully resolve in a few months after stopping the drug. When the patient's symptoms do not improve, it means VPA has unmasked the underlying potential for developing Parkinson's disease. Such patients benefit from levodopa therapy. However, the mechanism of how VPA causes Parkinsonism remains unknown. Based on the articles reviewed, we hypothesize that VPA's mechanism of neuronal inactivation by blocking membrane channels across the neuronal membrane, primarily when used chronically could be the mechanism by which it causes Parkinsonism. VPA causes down regulation of sodium and potassium channels on neuronal membrane in order to stop the neurons from firing. Thereby a decrease in action potential across the neurons causes a temporary physiological inactivation of the neuron. When multiple neurons are inactivated in the basal ganglia of the brain, the patient develops symptoms of Parkinsonism. As the neurons are only temporarily inactivated physiologically, when the drug is stopped the membrane receptors are reactivated on the neuronal membranes. This leads to neuronal activation and neuronal membrane potential becomes the same as before. The above mechanism clarifies why the symptoms settle down when the medication is stopped.
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Affiliation(s)
- Abilash Muralidharan
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
- Internal Medicine, Kiruba Hospital, Coimbatore, IND
| | - Jawaria Rahman
- Pathology, City of Hope Comprehensive Cancer Center, Monrovia, USA
| | - Dipanjan Banerjee
- Neuroscience, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
- Geriatrics, Queen's Medical Center, Nottingham University Hospitals NHS Trust, Nottingham, GBR
| | - Abdul Rub Hakim Mohammed
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Bilal Haider Malik
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
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13
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Zerah L, Bihan K, Kohler S, Mariani LL. Iatrogenesis and neurological manifestations in the elderly. Rev Neurol (Paris) 2020; 176:710-723. [PMID: 32389421 DOI: 10.1016/j.neurol.2019.11.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 11/22/2019] [Accepted: 11/26/2019] [Indexed: 12/20/2022]
Abstract
Older people are often exposed to polypharmacy in a multimorbidity context. Inappropriate polypharmacy is often harmful, increasing the risk of inappropriate prescriptions and therefore adverse drug events (ADEs). Five to 20% of all hospital admissions are related to ADE in older people, among which 40 to 70% could be prevented. However, identifying ADEs and drug-related admissions in the elderly is challenging because ADEs often present as common geriatric problems such as falls, delirium, which might be due to the aging process, underlying diseases, and/or medications. In the pharmacovigilance database of the World Health Organization, drug-related neurological manifestations are the third reported cause of ADEs in the elderly, and neurological drugs are the third leading class of medications involved in ADEs. We must therefore be particularly vigilant, both in our prescriptions but also in our diagnoses to avoid prescribing inappropriate treatments and detect ADEs. Even though multiple pharmacologic changes occur in the elderly (absorption, distribution, drug metabolism and excretion), most of medications are still often prescribed at the same daily dosage as in young adults. When prescribing any drug for old patients, we should remember that daily intake should be adapted to these specificities, keeping in mind the old well-known aphorism "start low, go slow". In this review, we describe the main drug-related neurological manifestations (drug-induced movement disorders, falls, seizures, delirium, hypoglycemia, stroke, hyponatremia, peripheral neuropathy and myopathy, and serotonin syndrome) and the main drugs associated with neurological manifestations (dopamine receptor blocking agents, antithrombotics, anticholinergics, beta-lactams, antidepressants, benzodiazepines, mood stabilizers).
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Affiliation(s)
- L Zerah
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP, Hôpitaux Universitaires Pitié-Salpêtrière-Charles Foix, Département de gériatrie, 75013 Paris, France
| | - K Bihan
- Sorbonne Université, Assistance Publique Hôpitaux de Paris, Regional Pharmacovigilance Center, Department of Pharmacology, Pitié-Salpêtrière Hospital, Paris, France
| | - S Kohler
- Hôpital Bretonneau, Service de Gériatrie à Orientation Psychiatrique - DMU INVICTUS - Paris nord Université - Assistance Publique-Hôpitaux de Paris, Paris, France
| | - L-L Mariani
- Sorbonne University, Assistance Publique-Hôpitaux de Paris, Brain and Spine Institute, ICM, Inserm U 1127, CNRS UMR 7225, Department of Neurology, Pitié-Salpêtrière Hospital, 75013 Paris, France.
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14
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Factor SA, Burkhard PR, Caroff S, Friedman JH, Marras C, Tinazzi M, Comella CL. Recent developments in drug-induced movement disorders: a mixed picture. Lancet Neurol 2019; 18:880-890. [PMID: 31279747 DOI: 10.1016/s1474-4422(19)30152-8] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Revised: 03/17/2019] [Accepted: 03/19/2019] [Indexed: 01/14/2023]
Abstract
A large and ever-growing number of medications can induce various movement disorders. Drug-induced movement disorders are disabling but are often under-recognised and inappropriately managed. In particular, second generation antipsychotics, like first generation agents, are associated with potentially debilitating side-effects, most notably tardive syndromes and parkinsonism, as well as potentially fatal acute syndromes. Appropriate, evidence-based management is essential as these drugs are being prescribed to a growing population vulnerable to these side-effects, including children and elderly people. Prevention of the development of drug-induced movement disorders is an important consideration when prescribing medications that can induce movement disorders. Recent developments in diagnosis, such as the use of dopamine transporter imaging for drug-induced parkinsonism, and treatment, with the approval of valbenazine and deutetrabenazine, the first drugs indicated for tardive syndromes, have improved outcomes for many patients with drug-induced movement disorders. Future research should focus on development of safer antipsychotics and specific therapies for the different tardive syndromes and the treatment of drug-induced parkinsonism.
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Affiliation(s)
- Stewart A Factor
- Jean and Paul Amos Parkinson's Disease and Movement Disorders Program, Emory University School of Medicine, Atlanta, GA, USA.
| | - Pierre R Burkhard
- Department of Neurology, Faculty of Medicine, Geneva University Hospitals, University of Geneva, Geneva, Switzerland
| | - Stanley Caroff
- Corporal Michael J Crescenz VA Medical Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Joseph H Friedman
- Butler Hospital, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Connie Marras
- Edmond J Safra Program in Parkinson's Research, University of Toronto, Toronto Western Hospital, Toronto, ON, Canada
| | - Michele Tinazzi
- Department of Neuroscience, Biomedicine, and Movement, University of Verona, Verona, Italy
| | - Cynthia L Comella
- Department of Neurological Sciences, Rush Medical College, Chicago, IL, USA
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Yomtoob J, Koloms K, Bega D. DAT-SPECT imaging in cases of drug-induced parkinsonism in a specialty movement disorders practice. Parkinsonism Relat Disord 2018; 53:37-41. [PMID: 29748111 DOI: 10.1016/j.parkreldis.2018.04.037] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Revised: 04/12/2018] [Accepted: 04/28/2018] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Compare clinical characteristics and outcomes in cases where DAT-SPECT imaging is used to distinguish Parkinson's disease from Drug-Induced Parkinsonsim. BACKGROUND Clinical uncertainty in diagnosing Parkinson's disease is common when patients are on dopamine-blocking medications. DAT-SPECT imaging can improve diagnostic certainty but little data are available on clinical characteristics and outcomes associated with normal and abnormal scan results. METHODS Retrospective chart review of patients seen at a movement disorders center between 2011 and 2017 where DAT-SPECT was ordered to distinguish Parkinson's disease from Drug-induced Parkinsonism. Descriptive statistics were calculated for variables of interest and compared by scan result. Chi-squared analyses was carried out for categorical variables and students' t-tests for continuous values. RESULTS 51 patients met inclusion criteria with 36 normal scans and 15 abnormal scans. Those with greater than 2 cardinal manifestations (tremor, rigidity, akinesia, postural instability) were more likely to have an abnormal scan (63.89% vs 93.33%, p = 0.04). No other clinical characteristics assessed were associated with scan results. Atypical antipsychotics (aripiprazole 39.21%, olanzapine 31.37%) and mood stabilizers (valproic acid 33.33%, lithium 17.65%) were most commonly associated with suspected Drug-induced Parkinsonism cases. A post-scan change in management occurred in 41.18% of patients. 55.56% of patients with normal scans responded to changes in the offending medication, with 16.66% taking over 3 months to show improvement. CONCLUSIONS Many DAT-SPECT scans at our institution are ordered to distinguish Parkinson's disease from Drug-induced Parkinsonism because clinical characteristics alone are unreliable. DAT-SPECT results lead to changes in management and the outcomes of these changes are consistent with scan results.
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Affiliation(s)
- Jacob Yomtoob
- Northwestern University Feinberg School of Medicine, United States
| | - Kimberly Koloms
- Northwestern University Feinberg School of Medicine, Department of Preventative Medicine, United States
| | - Danny Bega
- Northwestern University Feinberg School of Medicine, Department of Neurology, United States.
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Morgan JC, Kurek JA, Davis JL, Sethi KD. Insights into Pathophysiology from Medication-induced Tremor. Tremor Other Hyperkinet Mov (N Y) 2017; 7:442. [PMID: 29204312 PMCID: PMC5712675 DOI: 10.7916/d8fj2v9q] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2016] [Accepted: 10/19/2017] [Indexed: 02/08/2023] Open
Abstract
Background Medication-induced tremor (MIT) is common in clinical practice and there are many medications/drugs that can cause or exacerbate tremors. MIT typically occurs by enhancement of physiological tremor (EPT), but not all drugs cause tremor in this way. In this manuscript, we review how some common examples of MIT have informed us about the pathophysiology of tremor. Methods We performed a PubMed literature search for published articles dealing with MIT and attempted to identify articles that especially dealt with the medication's mechanism of inducing tremor. Results There is a paucity of literature that deals with the mechanisms of MIT, with most manuscripts only describing the frequency and clinical settings where MIT is observed. That being said, MIT emanates from multiple mechanisms depending on the drug and it often takes an individualized approach to manage MIT in a given patient. Discussion MIT has provided some insight into the mechanisms of tremors we see in clinical practice. The exact mechanism of MIT is unknown for most medications that cause tremor, but it is assumed that in most cases physiological tremor is influenced by these medications. Some medications (epinephrine) that cause EPT likely lead to tremor by peripheral mechanisms in the muscle (β-adrenergic agonists), but others may influence the central component (amitriptyline). Other drugs can cause tremor, presumably by blockade of dopamine receptors in the basal ganglia (dopamine-blocking agents), by secondary effects such as causing hyperthyroidism (amiodarone), or by other mechanisms. We will attempt to discuss what is known and unknown about the pathophysiology of the most common MITs.
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Affiliation(s)
- John C. Morgan
- Movement Disorders Program Parkinson’s Foundation Center of Excellence, Department of Neurology, Medical College of Georgia, Augusta, GA, USA
| | - Julie A. Kurek
- Movement Disorders Program Parkinson’s Foundation Center of Excellence, Department of Neurology, Medical College of Georgia, Augusta, GA, USA
| | - Jennie L. Davis
- Movement Disorders Program Parkinson’s Foundation Center of Excellence, Department of Neurology, Medical College of Georgia, Augusta, GA, USA
| | - Kapil D. Sethi
- Movement Disorders Program Parkinson’s Foundation Center of Excellence, Department of Neurology, Medical College of Georgia, Augusta, GA, USA
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Alonso-Juarez M, Torres-Russotto D, Crespo-Morfin P, Baizabal-Carvallo JF. The clinical features and functional impact of valproate-induced tremor. Parkinsonism Relat Disord 2017; 44:147-150. [PMID: 28941829 DOI: 10.1016/j.parkreldis.2017.09.011] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2017] [Revised: 08/15/2017] [Accepted: 09/09/2017] [Indexed: 11/18/2022]
Abstract
BACKGROUND Tremor is a known side-effect of anticonvulsants, particularly of valproate. However, there is a dearth of information regarding detailed clinical features and functional impact of valproate-induced tremor. METHODS We studied a cohort of patients treated with anticonvulsants for neurological disorders, through blinded evaluations using the Clinical Rating Scale for Tremor (CRST); we compared the frequency, severity and functional impact of drug-induced tremor between patients treated with valproate and those treated with other anticonvulsants. RESULTS From a cohort of 218 consecutive patients, 171 were fully evaluated; 118 patients were taking valproate alone or combined with other anticonvulsants and 53 patients were taking other anticonvulsants. Mean age (±SD) at evaluation of the cohort was 32 ± 13 years, females represented 55.6% of cases. Tremor was more frequently observed in patients taking valproate particularly postural upper limb tremor: 49% vs. 15% (right-side) (P < 0.001) and 48.3% vs. 13.2% (left-side), (P < 0.001); had a higher total CRST score: 12.14 vs. 3.06 (P < 0.001), and required more frequently treatment for drug-induced tremor: 23.7% vs. 5.6% (P=0.005) compared with patients taking other anticonvulsants. Among 118 patients taking valproate, women had a higher total CRST score compared with men: 14.54 ± 14.9 vs. 9.56 ± 9.55 (P=0.034). A weak correlation between the total CRST score, dose per Kg of valproate and serum levels of valproate were observed. CONCLUSIONS Tremor is frequently observed in patients taking valproate and is severe enough to require treatment in about 24% of cases.
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18
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Caruana Galizia E, Isaacs JD, Cock HR. Non-hyperammonaemic valproate encephalopathy after 20 years of treatment. EPILEPSY & BEHAVIOR CASE REPORTS 2017. [PMID: 28649495 PMCID: PMC5470621 DOI: 10.1016/j.ebcr.2017.04.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Sodium valproate is a commonly used antiseizure drug with broad indications for different seizuretypes and epilepsy syndromes. Well-recognised side effects include weight gain, tremor, dizziness, and unsteadiness. Non-hyperammonaemic parkinsonism, with or without cognitive impairment, is a rare adverse effect of sodium valproate. We present the case of a sixty year-old lady with a generalized seizure disorder, treated with phenytoin, valproate, lamotrigine and clonazepam. Following withdrawal of phenytoin she developed an akinetic-rigid syndrome, with ataxia and marked cognitive impairment. Extensive investigation failed to identify a cause. Serum ammonia and valproate levels were normal. Hypothesizing this might be valproate encephalopathy, valproate was rapidly substituted with levetiracetam. Her severe motor symptoms resolved within two weeks and cognitive impairment markedly improved. Valproate-induced encephalopathy, with or without hyperammonaemia and liver toxicity are typically recognizable for their temporal relation between the start of therapy with valproate and emergence of the clinical syndrome. Reversible disorders of motor function and cognition attributable to valproate are well described, but few cases have been reported presenting years after starting treatment. Given the insidious progression, delayed onset, lack of association with drug levels or presence of hyperammonaemia, a high index of suspicion is needed to make the diagnosis.
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Affiliation(s)
- Elizabeth Caruana Galizia
- Atkinson Morley Regional Neuroscience Centre, St Georges University Hospitals NHS Foundation Trust, London SW17 0QT, United Kingdom
| | - Jeremy D Isaacs
- Atkinson Morley Regional Neuroscience Centre, St Georges University Hospitals NHS Foundation Trust, London SW17 0QT, United Kingdom
| | - Hannah R Cock
- Atkinson Morley Regional Neuroscience Centre, St Georges University Hospitals NHS Foundation Trust, London SW17 0QT, United Kingdom.,Institute of Medical & Biomedical Education, St Georges University of London, SW17 0RE, United Kingdom
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19
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Friedman JH. Drug-induced parkinsonism. Mov Disord 2017; 32:1111. [DOI: 10.1002/mds.27050] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2017] [Accepted: 04/07/2017] [Indexed: 11/05/2022] Open
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20
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Can Valproic Acid Regulate Neurogenesis from Nestin+ Cells in the Adult Midbrain? Neurochem Res 2017; 42:2127-2134. [PMID: 28434161 DOI: 10.1007/s11064-017-2259-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Revised: 03/10/2017] [Accepted: 03/31/2017] [Indexed: 02/04/2023]
Abstract
Degeneration of dopamine (DA) neurons in the substantia nigra pars compacta (SNc) causes the motor symptoms (e.g. tremor, muscle rigidity, bradykinesia, postural instability) of Parkinson's disease (PD). It is generally agreed that replacing these neurons will provide better motor symptom relief and fewer side effects than current pharmacotherapies. One potential approach to this is up-regulating endogenous DA neurogenesis in SNc. In the present study, we conducted bioinformatics analyses to identify signalling pathways that control expression of Pax6 and Msx1 genes, which have been identified as potentially important neurogenic regulators in the adult midbrain. From this Valproic acid (VPA) was identified as a regulator of these pathways, and we tested VPA for its ability to regulate midbrain neurogenesis in adult mice. VPA was infused directly into the midbrain of adult NesCreERT2/R26eYFP mice using osmotic pumps attached to implanted cannula. These mice enable permanent eYFP+ labelling of adult Nestin-expressing neural precursor cells and their progeny/ontogeny. VPA did not affect the number of eYFP+ midbrain cells, but significantly reduced the number of Pax6+, Pax6+/NeuN+, eYFP+/NeuN+ and eYFP-/NeuN+ cells. However, this reduction in NeuN expression was probably via VPA's Histone de-acetylase inhibitory properties rather than reduced neuronal differentiation by eYFP + cells. We conclude that Pax6 and Msx1 are not viable targets for regulating neurogenesis in the adult midbrain.
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21
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Tremblay M, Silveira MM, Kaur S, Hosking JG, Adams WK, Baunez C, Winstanley CA. Chronic D 2/3 agonist ropinirole treatment increases preference for uncertainty in rats regardless of baseline choice patterns. Eur J Neurosci 2016; 45:159-166. [PMID: 27422144 DOI: 10.1111/ejn.13332] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2016] [Revised: 06/08/2016] [Accepted: 07/03/2016] [Indexed: 12/17/2022]
Abstract
D2/3 receptor agonists are effective treatments for Parkinson's disease (PD), but can precipitate impulse control disorders (ICDs) including gambling disorder (GD). The neurobiological mechanisms underlying this devastating side-effect of dopamine agonist replacement therapy (DRT), and any dependence on the dopamine depletion caused by PD, are unclear. It is also unclear whether previous biases towards risk or uncertainty are a risk factor for developing these ICDs. We investigated whether chronic D2/3 agonist administration (5 mg/kg/day ropinirole for 28 days) altered performance of a rat model of gambling-like behaviour, the rodent betting task (rBT), and examined if baseline behaviour predicted this behavioural change. The rBT captures individual differences in subjective preference for uncertain outcomes: animals choose between guaranteed or probabilistic reinforcement of equal expected value. Chronic ropinirole dramatically increased selection of the uncertain option in two-thirds of animals, regardless of baseline preferences. The effect on choice in the rBT was replicated in a dorsolateral striatal 6-hydroxydopamine (6-OHDA) rat model of early PD. These studies are the first to look at individual differences in response to chronic, rather than pulsatile, dosing of DRT in a rodent model of gambling behaviour. These findings suggest that DRT-induced PG may stem from increases in subjective valuation of uncertainty. Such symptoms likely arise because of changes in dopaminergic striatal signalling caused by DRT rather than from an interaction between pre-morbid behaviours or PD itself.
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Affiliation(s)
- Melanie Tremblay
- Department of Psychology, University of British Columbia, 2136 West Mall, Vancouver, BC, V6T 1Z4, Canada
| | - Mason M Silveira
- Department of Psychology, University of British Columbia, 2136 West Mall, Vancouver, BC, V6T 1Z4, Canada
| | - Sukhbir Kaur
- Department of Psychology, University of British Columbia, 2136 West Mall, Vancouver, BC, V6T 1Z4, Canada
| | - Jay G Hosking
- Department of Psychology, University of British Columbia, 2136 West Mall, Vancouver, BC, V6T 1Z4, Canada
| | - Wendy K Adams
- Department of Psychology, University of British Columbia, 2136 West Mall, Vancouver, BC, V6T 1Z4, Canada
| | - Christelle Baunez
- Institut de Neurosciences de la Timone (INT), UMR7289, Centre National de la Recherche Scientifique (CNRS) & Aix-Marseille Université (AMU), Marseille, France
| | - Catharine A Winstanley
- Department of Psychology, University of British Columbia, 2136 West Mall, Vancouver, BC, V6T 1Z4, Canada
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22
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Abstract
Valproate was first approved as an antiepileptic drug in 1962 and has since also become established as a mood stabiliser and as prophylaxis for migraine. In 1979, Lautin published the first description of a valproate-associated extrapyramidal syndrome. Many cases of valproate-associated parkinsonism have subsequently been published, but uncertainties remain concerning its prevalence, risk factors and prognosis. The aim of this paper is to provide a critical review of the existing literature on valproate-associated parkinsonism and to discuss possible mechanisms. Literature databases were searched systematically: we identified a total of 116 patients with valproate-associated parkinsonism published in case reports, case series and systematic analyses. Prevalence rates ranged widely, between 1.4 and 75 % of patients taking valproate. There was great heterogeneity with regard to clinical presentation, age of onset, valproate dose, concomitant conditions and imaging findings. In all patients apart from three, valproate plasma concentrations were within or even below the recommended reference range when the parkinsonism occurred. Parkinsonism was reversible in the majority of patients, although recovery was often prolonged and sometimes incomplete. A dopaminergic deficit was confirmed in three of six patients investigated with dopamine transporter imaging. Seven of 14 patients who were treated with dopaminergic medication had a good response. The quality of the evidence was assessed and probability of causation was examined using the Naranjo score, which ranged from 0 to 7 (median: 5.0). Several pathophysiological mechanisms, including altered gene expression and neurotransmitter signalling, enhanced neurodegeneration or unmasking subclinical dopaminergic degeneration, could theoretically lead to valproate-associated parkinsonism. Further studies are warranted to elucidate this entity and its underlying pathophysiology.
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Affiliation(s)
- Florian Brugger
- Sobell Department of Motor Neuroscience and Movement Disorders, UCL Institute of Neurology, Queen Square, London, UK.,Department of Neurology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Kailash P Bhatia
- Sobell Department of Motor Neuroscience and Movement Disorders, UCL Institute of Neurology, Queen Square, London, UK
| | - Frank M C Besag
- ELFT NHS Family Consultation Clinic, 24 Grove Place, Bedford, Bedfordshire, MK40 3JJ, UK. .,School of Pharmacy, University College of London, London, UK. .,Institute of Psychiatry, London, UK.
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23
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Hamed SA, Abdellah MM. The relationship between valproate induced tremors and circulating neurotransmitters: a preliminary study. Int J Neurosci 2016; 127:236-242. [PMID: 27161592 DOI: 10.1080/00207454.2016.1181631] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Jiménez-Urbieta H, Gago B, de la Riva P, Delgado-Alvarado M, Marin C, Rodriguez-Oroz MC. Dyskinesias and impulse control disorders in Parkinson's disease: From pathogenesis to potential therapeutic approaches. Neurosci Biobehav Rev 2015. [PMID: 26216865 DOI: 10.1016/j.neubiorev.2015.07.010] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Dopaminergic treatment in Parkinson's disease (PD) reduces the severity of motor symptoms of the disease. However, its chronic use is associated with disabling motor and behavioral side effects, among which levodopa-induced dyskinesias (LID) and impulse control disorders (ICD) are the most common. The underlying mechanisms and pathological substrate of these dopaminergic complications are not fully understood. Recently, the refinement of imaging techniques and the study of the genetics and molecular bases of LID and ICD indicate that, although different, they could share some features. In addition, animal models of parkinsonism with LID have provided important knowledge about mechanisms underlying such complications. In contrast, animal models of parkinsonism and abnormal impulsivity, although useful regarding some aspects of human ICD, do not fully resemble the clinical phenotype of ICD in patients with PD, and until now have provided limited information. Studies on animal models of addiction could complement the previous models and provide some insights into the background of these behavioral complications given that ICD are regarded as behavioral addictions. Here we review the most relevant advances in relation to imaging, genetics, biochemistry and pharmacological interventions to treat LID and ICD in patients with PD and in animal models with a view to better understand the overlapping and unique maladaptations to dopaminergic therapy that are associated with LID and ICD.
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Affiliation(s)
- Haritz Jiménez-Urbieta
- Biodonostia Research Institute, 20014 San Sebastián, Spain; Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas (CIBERNED), Spain.
| | - Belén Gago
- Biodonostia Research Institute, 20014 San Sebastián, Spain; Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas (CIBERNED), Spain.
| | | | - Manuel Delgado-Alvarado
- Biodonostia Research Institute, 20014 San Sebastián, Spain; Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas (CIBERNED), Spain.
| | - Concepció Marin
- INGENIO, IRCE, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) , 08036 Barcelona, Spain.
| | - María C Rodriguez-Oroz
- Biodonostia Research Institute, 20014 San Sebastián, Spain; Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas (CIBERNED), Spain; University Hospital Donostia, 20014 San Sebastián, Spain; Ikerbasque (Basque Foundation for Science), 48011 Bilbao, Spain.
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25
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26
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Athauda D, Batley R, Ellis C. Clinically silent idiopathic Parkinson's disease unmasked by valproate use: a brief report. Aging Clin Exp Res 2015; 27:387-90. [PMID: 25365950 DOI: 10.1007/s40520-014-0278-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Accepted: 10/23/2014] [Indexed: 10/24/2022]
Abstract
Valproate is an important but uncommon cause of drug induced parkinsonism in the elderly. The development of symptoms after valproate onset is unpredictable, and severity of symptoms is unrelated to plasma levels. However, though the majority of cases improve after drug cessation, parkinsonian symptoms can persist and should prompt investigation into underlying degenerative parkinsonism, as valproate can unmask idiopathic Parkinson's disease in susceptible individuals. This case describes a patient on chronic valproate therapy developing a severely disabling akinetic-rigid syndrome, only partially reversed on stopping valproate. We hypothesise that an increase in valproate dosage unmasked clinically silent Parkinson's disease. The patient made an excellent recovery following cessation of valproate and commencement of dopaminergic therapy.
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27
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Gorman DA, Gardner DM, Murphy AL, Feldman M, Bélanger SA, Steele MM, Boylan K, Cochrane-Brink K, Goldade R, Soper PR, Ustina J, Pringsheim T. Canadian guidelines on pharmacotherapy for disruptive and aggressive behaviour in children and adolescents with attention-deficit hyperactivity disorder, oppositional defiant disorder, or conduct disorder. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2015; 60:62-76. [PMID: 25886657 PMCID: PMC4344948 DOI: 10.1177/070674371506000204] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Accepted: 11/01/2014] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To develop evidence-based guidelines on pharmacotherapy for severe disruptive and aggressive behaviour in children and adolescents with attention-deficit hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), or conduct disorder (CD). The guidelines assume that psychosocial interventions have been pursued but did not achieve sufficient improvement. METHOD A multidisciplinary consensus group used the Grading of Recommendations Assessment, Development and Evaluation approach for rating evidence quality and for grading recommendations. We conducted a systematic review of medications studied in placebo-controlled trials for treating disruptive and aggressive behaviour in children and adolescents with ADHD, ODD, or CD. We followed consensus procedures to make 1 of 4 recommendations for each medication: strong, in favour (↑↑); conditional, in favour (↑?); conditional, against (↓?); and strong, against (↓↓). RESULTS For children and adolescents with disruptive or aggressive behaviour associated with ADHD, psychostimulants received a strong recommendation in favour of use, while atomoxetine and alpha-2 agonists received a conditional recommendation in favour of use. If these patients do poorly with ADHD medications, the medication with the most evidence is risperidone. Risperidone also has the most evidence for treating disruptive or aggressive behaviour in the absence of ADHD. However, given risperidone's major adverse effects, it received only a conditional recommendation in favour of use. We recommended against using quetiapine, haloperidol, lithium, or carbamazepine because of the poor quality of evidence and their major adverse effects. CONCLUSION When severe disruptive or aggressive behaviour occurs with ADHD, medications for ADHD should be used first. Other medications have major adverse effects and, with the exception of risperidone, very limited evidence to support their use.
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Affiliation(s)
- Daniel A Gorman
- Assistant Professor, Department of Psychiatry, University of Toronto, Toronto, Ontario; Psychiatrist, The Hospital for Sick Children, Toronto, Ontario
| | - David M Gardner
- Professor, Department of Psychiatry and College of Pharmacy, Dalhousie University, Halifax, Nova Scotia
| | - Andrea L Murphy
- Associate Professor, Department of Psychiatry and College of Pharmacy, Dalhousie University, Halifax, Nova Scotia
| | - Mark Feldman
- Associate Professor, Department of Paediatrics, University of Toronto, Toronto, Ontario; Paediatrician, The Hospital for Sick Children and St Joseph's Health Centre, Toronto, Ontario
| | - Stacey A Bélanger
- Clinical Assistant Professor, Department of Paediatrics, Université de Montréal, Montreal, Quebec; Paediatrician (Diplôme d'études spécialisées Paediatric Neurology), Centre hospitalier universitaire Sainte-Justine, Montreal, Quebec
| | - Margaret M Steele
- Professor, Departments of Psychiatry, Family Medicine, and Paediatrics, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario
| | - Khrista Boylan
- Assistant Professor, Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario
| | - Kate Cochrane-Brink
- Lecturer, Department of Psychiatry, University of Toronto, Toronto, Ontario; Psychiatrist, Youthdale Treatment Centres, Toronto, Ontario
| | - Roxanne Goldade
- Clinical Assistant Professor, Department of Paediatrics, University of Calgary, Calgary, Alberta
| | - Paul R Soper
- Child and Adolescent Psychiatrist, Glenrose Attention-Deficit Hyperactivity Disorder Clinic, Edmonton, Alberta
| | - Judy Ustina
- Clinical Lecturer, Department of Psychiatry, University of Alberta, Edmonton, Alberta
| | - Tamara Pringsheim
- Assistant Professor, Department of Clinical Neurosciences, Psychiatry, Community Health Sciences, and Paediatrics, University of Calgary, Calgary, Alberta; Neurologist, Director, Calgary Tourette and Paediatric Movement Disorders Clinic, Calgary, Alberta
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Abstract
Myoclonus creates significant disability for patients. This symptom or sign can have many different etiologies, presentations, and pathophysiological mechanisms. A thorough evaluation for the myoclonus etiology is critical for developing a treatment strategy. The best etiological classification scheme is a modified version from that proposed by Marsden et al. in 1982. Clinical neurophysiology, as assessed by electromyography and electroencephalography, can be used to classify the pathophysiology of the myoclonus using a neurophysiology classification scheme. If the etiology of the myoclonus cannot be reversed or treated, then symptomatic treatment of the myoclonus itself may be warranted. Unfortunately, there are few controlled studies for myoclonus treatments. The treatment strategy for the myoclonus is best derived from the neurophysiology classification scheme categories: 1) cortical, 2) cortical-subcortical, 3) subcortical-nonsegmental, 4) segmental, and 5) peripheral. A cortical physiology classification is most common. Levetiracetam is suggested as first-line treatment for cortical myoclonus, but valproic acid and clonazepam are commonly used. Cortical-subcortical myoclonus is the physiology demonstrated by myoclonic seizures, such as in primary epileptic myoclonus (e.g., juvenile myoclonic epilepsy). Valproic acid has demonstrated efficacy in such epileptic syndromes with other medications providing an adjunctive role. Clonazepam is used for subcortical-nonsegmental myoclonus, but other treatments, depending on the syndrome, have been used for this physiological type of myoclonus. Segmental myoclonus is difficult to treat, but clonazepam and botulinum toxin are used. Botulinum toxin is used for focal examples of peripheral myoclonus. Myoclonus treatment is commonly not effective and/or limited by side effects.
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Affiliation(s)
- John N Caviness
- Department of Neurology, Mayo Clinic Arizona, 13400 East Shea Blvd., Scottsdale, AZ, 85259, USA,
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George M, Haasz M, Coronado A, Salhanick S, Korbel L, Kitzmiller JP. Acute dyskinesia, myoclonus, and akathisa in an adolescent male abusing quetiapine via nasal insufflation: a case study. BMC Pediatr 2013; 13:187. [PMID: 24238149 PMCID: PMC4225618 DOI: 10.1186/1471-2431-13-187] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2013] [Accepted: 11/06/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Although the benefits of antipsychotic pharmacotherapy can be pronounced, many patients develop unwanted adverse effects including a variety of movement disorders. Compared with the traditional antipsychotics, the atypical antipsychotics have a decreased risk for associated movement disorders. Drug-induced movement disorders can occur, however, and the risk of adverse events can increase significantly when medications are abused. CASE PRESENTATION We describe the case of a 13-year-old male who presented to an emergency department with acute movement disorders after nasal insufflation of crushed quetiapine. The patient was admitted and successfully treated for neuroleptic toxicity with intravenous antihistamine pharmacotherapy. His primary care provider and psychiatrist were notified of the abuse, quetiapine was discontinued, and the patient was discharged and referred to a drug and alcohol awareness and abuse program. CONCLUSIONS The abuse of quetiapine has unfortunately become more common. This unique case report of acute movement disorders following nasal insufflation of quetiapine highlights the need for heightened vigilance when prescribing quetiapine and for increased awareness and education regarding medication-abuse.
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Affiliation(s)
- Mathew George
- Department of Pediatrics, St, Barnabas Hospital, 4432 3rd avenue, Bronx, NY 10457, USA.
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