[Pergolide treatment and cardiac valve pathology: the continuing saga of ergotamine-induced fibrosis]

Restless legs syndrome: pathophysiology, diagnosis and treatment

Restless legs syndrome (RLS) is clinically defined by the presence of (i) an urge to move the legs with or without an actual paraesthesia; (ii) a worsening of symptoms with inactivity; (iii) improvement with activity; and (iv) a worsening of symptoms in the evening and at night. Patients may use a variety of semantic phrases to describe their symptoms but all must have an urge to move. Most people with RLS also have periodic limb movements during sleep, although this is not part of the clinical diagnostic criteria. RLS is very common. About 10% of all Caucasian populations have RLS, although it may be mild in the majority of cases. Women generally outnumber men by about 2:1. As a general rule, RLS severity worsens through the first seven to eight decades of life, but may actually lessen in old age. The aetiology of RLS is only partly understood. There is a strong genetic component, and several genetic linkages and three causative genes have been identified worldwide. Several medical conditions, including renal failure, systemic iron deficiency and pregnancy, and possibly neuropathy, essential tremor and some genetic ataxias, are also associated with high rates of RLS. In all cases to date, the actual CNS pathology of RLS demonstrates reduced iron stores, in a pattern that suggests that the homeostatic control of iron is altered, not just that there is not enough iron entering the brain. The relationship between reduced CNS iron levels and the clinical phenotype or treatment response to dopaminergics is not known but generates promising speculation. Treatment of RLS is usually rewarding. Most patients respond robustly to dopamine receptor agonists. Over time, response may lessen, or the patients may develop 'augmentation', whereby they have a worsening of symptoms, usually in the form of an earlier onset. Other treatment options include gabapentin, or similar antiepileptic drugs, and opioids. High-dose intravenous iron is a promising but still experimental approach.

Médicaments, maladie de Parkinson et syndromes parkinsoniens : actualités de pharmacovigilance

This paper reviews recent data on the pharmacovigilance of antiparkinsonian drugs and drugs inducing parkinsonian syndroms. Sudden sleep attacks were first described in 1999 with dopamine agonists. In fact, they can be induced by all the dopaminergic antiparkinsonian drugs. Favorising factors are duration of the disease, dose of dopaminergic drugs, daytime somnolence or dysautonomia. This adverse drug reaction can be serious leading, for example, to road accidents. Cardiac valvulopathies were more recently (end of 2002) described with pergolide. Thus, this dopamine agonist should now be prescribed as a last choice among dopamine agonists. Dopamine drugs (levodopa as well as dopamine agonists) can induce hypersexual behaviours or pathological gambling. Among the long list of drugs inducing parkinsonian syndroms, recent data suggest the involvement of serotoninergic antidepressants, valproic acid and trimetazidine. Finally, these data on pharmacovigilance allow to precise the physiological role of dopamine: beside its motor and psychic effects, dopamine is also involved in the sleep-arousal control. It is also an important mediator for pleasure, hedonic regulations and sexual behaviour. This review also underlines the major role of spontaneous reports to the pharmacovigilance systems to identify new adverse drug reactions.

Valvulopathies sous pergolide : revue critique de la littérature et conduite à tenir en pratique

INTRODUCTION

Pergolide is a widely used antiparkinsonian dopamine agonist. Following occasional case reports, two studies recently suggested potentially frequent and severe valvular disease associated with pergolide intake.

STATE OF ART

Although there is now strong evidence to consider that pergolide may induce valvulopathy, incidence, severity, and risk factors for this adverse effect remain to be clarified. Valvular disease associated with pergolide consists in fibrosis and resembles conditions described in carcinoid carcinoma and in patients taking fenfluramine therapy. The mechanisms leading to valvular fibrosis are unknown but involvement of 5-HT(2B) receptors, especially expressed in valvular fibroblasts, is suspected.

PERSPECTIVES AND CONCLUSIONS

Following the recommendations of the Agence Française de Sécurité Sanitaire des Produits de Santé, we describe a clinical practice attitude for pergolide therapy in Parkinson's disease.