Hypersexuality Possibly Associated With Safinamide

New pharmacological and neuromodulation approaches for impulsive-compulsive behaviors in Parkinson's disease

INTRODUCTION

A significant proportion of patients with Parkinson's disease (PD) display a set of impulsive-compulsive behaviors at some point during the course of illness. These behaviors range from the so-called behavioral addictions to dopamine dysregulation syndrome, punding and hoarding disorders. These behaviors have been consistently linked to the use of dopaminergic medications used to treat PD motor symptoms (dopamine agonists, levodopa, and other agents) and less consistently to neuromodulation techniques such as deep brain stimulation (DBS). Since there are still no approved treatments for these conditions, their pharmacological management is still a big challenge for clinicians.

METHODS

We conducted an extensive review of current pharmacological and neuromodulation literature for the management of impulsive-compulsive disorders in PD patients.

RESULTS

Pharmacological treatment approaches for impulsive-compulsive behaviors and DDS in PD patients include reduction of levodopa (LD), reduction/cessation of dopamine agonist (DA), and initiation of infusion therapies (apomorphine infusion and duodopa). Also, atomoxetine, a noradrenergic agent approved for the treatment of attention deficit hyperactivity disorder, showed some interesting preliminary results but there is still a lack of controlled longitudinal studies. Finally, while DBS effects on impulsive-compulsive disorders are still controversial, non-invasive techniques (such as transcranial magnetic stimulation and transcranial direct current stimulation) could have a potential positive effect but, again, there is still a lack of controlled trials.

CONCLUSION

Managing impulsivity and compulsivity in PD patients is still a non-evidence-based challenge for clinicians. Controlled trials on promising approaches such as atomoxetine and non-invasive neuromodulation techniques are needed.

A Spanish Consensus on the Use of Safinamide for Parkinson's Disease in Clinical Practice

Safinamide is an approved drug for the treatment of fluctuations in Parkinson's disease (PD). Scarce data are available on its use in clinical practice. A group of Spanish movement disorders specialists was convened to review the use of safinamide across different clinical scenarios that may guide neurologists in clinical practice. Eight specialists with recognized expertise in PD management elaborated the statements based on available evidence in the literature and on their clinical experience. The RAND/UCLA method was carried, with final conclusions accepted after a 2-round modified Delphi process. Higher level of agreement between panellists was reached for the following statements. Safinamide significantly improves mean daily ON time without troublesome dyskinesias [corrected]. Adjunctive treatment with safinamide is associated with motor improvements in patients with mid-to-late PD. The efficacy of safinamide on motor fluctuations is maintained at long-term, with no increase over time in dyskinesias severity. The clinical benefits of safinamide on pain and depression remain unclear. Safinamide presents a similar incidence of adverse events compared with placebo. The efficacy and safety of safinamide shown in the pivotal clinical trials are reproduced in clinical practice, with improvement of parkinsonian symptoms, decrease of daily OFF time, control of dyskinesias at the long term, and good tolerability and safety.

Recurrent Episodes of Paraphilic Behavior Possibly Associated With Olanzapine and Aripiprazole Treatment in a Patient With Schizophrenia

BACKGROUND

Hypersexual and paraphilic disorders have been frequently associated with concomitant psychiatric disorders, including schizophrenia. A growing number of published cases has recently indicated that hypersexual behavior may also arise in conjunction with treatment with second-generation antipsychotics. Although hypersexuality has been acknowledged as a possible side effect of antipsychotic treatment with partial dopamine agonists, including aripiprazole, only very few cases of olanzapine-associated hypersexuality have been reported in the literature.

CASE PRESENTATION

A 29-year-old man presented with delusions of persecution and reference, auditory hallucinations, and negative symptoms, and was diagnosed with paranoid-hallucinatory schizophrenia. One and a half months after initiation of antipsychotic treatment with olanzapine, he developed compulsive sexual behavior and paraphilia, without signs of akathisia. After olanzapine discontinuation, a full remission of the hypersexual behavior was noted within one week, and treatment was switched to risperidone. Due to hyperprolactinemia, adjunct treatment with low-dose aripiprazole was initiated and a severe recurrence of identical hypersexual behavior occurred. The hypersexual behavior resolved completely within a week after aripiprazole discontinuation.

CONCLUSION

This case illustrates that hypersexuality may be a rare adverse effect of treatment with second-generation antipsychotics. Although aripiprazole is a drug with a well-established risk for hypersexuality, the question of whether a causal association between hypersexuality and olanzapine exists remains currently unresolved. As the currently limited amount of available evidence precludes any definitive conclusions, additional research is warranted to delineate the possible neurobiological substrates of hypersexual and paraphilic disorders in patients treated with second-generation antipsychotics.