High exposure compared with standard exposure to metoclopramide associated with a higher risk of parkinsonism: a nationwide population-based cohort study

Drug-induced parkinsonism: diagnosis and treatment

INTRODUCTION

Drug-induced parkinsonism (DIP) is one of the most common iatrogenic movement disorders. It is characterized by tremors, slowness of movement, and shuffling gait with postural instability, clinically indistinguishable from idiopathic Parkinson's disease. Prior exposure to antipsychotic medications or other dopamine receptor blocking agents (DRBAs) is required for the diagnosis.

AREAS COVERED

This article aims to review the epidemiology, pathophysiology, clinical features, ancillary testing, and treatment of DIP. A literature search was undertaken in PubMed from January 2013 to January 2024.

EXPERT OPINION

A clinician's suspicion of DIP must always be present when a patient develops acute to subacute onset of parkinsonism while taking a DRBA. As DIP can be indistinguishable from idiopathic PD, ancillary testing, such as DaTscans and skin biopsy searching for alpha-synuclein deposits, are often required to make a definitive diagnosis. When DIP develops, steps should be taken to discontinue the offending agent or, in the case of antipsychotics, dose reduction or change to an agent with lower risk for DIP, such as quetiapine or clozapine. Prophylactic treatment with anticholinergics is not indicated.

Outcome of Drug-Induced Parkinsonism in the Elderly: A Permanent Nonprogressive Parkinsonian Syndrome May Occur Following Discontinuation of Cinnarizine and Flunarizine

Parkinsonism induced by dopamine receptor antagonists, traditionally considered completely reversible following offending drug withdrawal, may unmask a degenerative parkinsonism in the patients with an underlying subclinical disease. In elderly patients, parkinsonism induced by the calcium channel blockers such as piperazine derivates cinnarizine and flunarizine may persist following drug discontinuation resulting in a permanent nonprogressive syndrome fulfilling the criteria for tardive parkinsonism. Whether this outcome occurs also following exposure to dopamine receptor antagonists such as neuroleptics and benzamide derivates or represents a class effect of the voltage-gated L-type calcium channel blockers, such as cinnarizine and flunarizine, due to their complex pharmacodynamic properties remains to be established.

Comprehensive management of adults with chronic migraine: Clinical practice guidelines in Mexico

Introduction:

Migraine is a polygenic multifactorial disorder with a neuronal initiation of a cascade of neurochemical processes leading to incapacitating headaches. Headaches are generally unilateral, throbbing, 4–72 h in duration, and associated with nausea, vomiting, photophobia, and sonophobia. Chronic migraine (CM) is the presence of a headache at least 15 days per month for ≥3 months and has a high global impact on health and economy, and therapeutic guidelines are lacking.

Methods:

Using the Grading of Recommendations, Assessment, Development, and Evaluations system, we conducted a search in MEDLINE and Cochrane to investigate the current evidence and generate recommendations of clinical practice on the identification of risk factors and treatment of CM in adults.

Results:

We recommend avoiding overmedication of non-steroidal anti-inflammatory drugs (NSAIDs); ergotamine; caffeine; opioids; barbiturates; and initiating individualized prophylactic treatment with topiramate eptinezumab, galcanezumab, erenumab, fremanezumab, or botulinum toxin. We highlight the necessity of managing comorbidities initially. In the acute management, we recommend NSAIDs, triptans, lasmiditan, and gepants alone or with metoclopramide if nausea or vomiting. Non-pharmacological measures include neurostimulation.

Conclusions:

We have identified the risk factors and treatments available for the management of CM based on a grading system, which facilitates selection for individualized management.

Antidopaminergic-Antiparkinsonian Medication Prescribing Cascade in Persons with Alzheimer's Disease

OBJECTIVES

Persons living with Alzheimer's disease (AD) may be at increased risk for prescribing cascades due to greater multimorbidity, polypharmacy, and the need for more complex care. Our objective was to assess the proportion of the antidopaminergic-antiparkinsonian medication prescribing cascades among persons living with Alzheimer's disease.

SETTING

Two large administrative claims databases in the United States.

PARTICIPANTS

We identified patients aged ≥50 on January 1, 2017, who were dispensed a drug used to treat Alzheimer's disease for at least 1 day in the 365 days prior to or on cohort entry date and who had medical and pharmacy coverage in the 365 days prior to the cohort entry date. We excluded individuals with a recent institutional stay. We identified incident antidopaminergic (antipsychotic/metoclopramide) use in the 183 days following cohort entry and identified subsequent incident antiparkinsonian drug use within 8 to 365 days.

RESULTS

There were 121,538 patients with Alzheimer's disease eligible for inclusion. Approximately 62% were women with a mean age of 79.5 (SD ± 8.6). The mean number of drugs dispensed was 9.2 (SD ± 4.9). There were 36 incident antiparkinsonian users among 4,534 incident antipsychotic/metoclopramide users (0.8%).

CONCLUSION

We determined that the proportion of antidopaminergic-antiparkinsonian medication prescribing cascades, widely considered as high-priority, was low. Our approach can be used to assess the proportion of prescribing cascades in populations considered to be at high risk and to prioritize system-level interventional efforts to improve medication safety in these patients.

[Prevention and treatment of antineoplastic drug-induced nausea and vomiting in pediatric onco-hematology: An update]

Antineoplastic drug induced nausea and vomiting are common adverse events in cancer care of paediatric patients ; therefore, prevention and management of these adverse events is a major concern for healthcare professionals. There are common features between paediatric and adult patients in terms of the emetogenic level depending on antineoplastic agents or about available medicines. However, there are also specificities for paediatric population including individual risk factors of emesis or nausea assessment for example. Knowledge relative to available medicines is also limited in the paediatric population, especially for recent medicines. This review aims to provide a comprehensive overview about antiemetics in paediatric oncology to clinicians and other healthcare professionals involved in paediatric cancer care. First of all, we describe physiopathological paediatric specificity, risk factors and clinical assessment of antineoplastic drug induced nausea and vomiting. Secondly, we focus on available medicines and also address the issue of complementary and alternative medicines.

What Can We Learn About Drug Safety and Other Effects in the Era of Electronic Health Records and Big Data That We Would Not Be Able to Learn From Classic Epidemiology?

As more and more health systems have converted to the use of electronic health records, the amount of searchable and analyzable data is exploding. This includes not just provider or laboratory created data but also data collected by instruments, personal devices, and patients themselves, among others. This has led to more attention being paid to the analysis of these data to answer previously unaddressed questions. This is especially important given the number of therapies previously found to be beneficial in clinical trials that are currently being re-scrutinized. Because there are orders of magnitude more information contained in these data sets, a fundamentally different approach needs to be taken to their processing and analysis and the generation of knowledge. Health care and medicine are drivers of this phenomenon and will ultimately be the main beneficiaries. Concurrently, many different types of questions can now be asked using these data sets. Research groups have become increasingly active in mining large data sets, including nationwide health care databases, to learn about associations of medication use and various unrelated diseases such as cancer. Given the recent increase in research activity in this area, its promise to radically change clinical research, and the relative lack of widespread knowledge about its potential and advances, we surveyed the available literature to understand the strengths and limitations of these new tools. We also outline new databases and techniques that are available to researchers worldwide, with special focus on work pertaining to the broad and rapid monitoring of drug safety and secondary effects.

Metoclopramide as a prokinetic agent for diabetic gastroparesis: revisiting the risk of Parkinsonism

Background:

Metoclopramide is used to relieve gastrointestinal symptoms, however, it could cause adverse reactions of motor disorders. The aim of this study was to investigate whether metoclopramide treatment has a duration–response or dose–response effect and to estimate the risk of developing Parkinsonism following different and specific durations of treatment.

Methods:

A cohort study of newly diagnosed type 2 diabetes mellitus in 45- to 79-year-old patients, between 1999 and 2008, was selected using the Longitudinal Health Insurance Database 2005. A nested case–control study was conducted in the diabetes cohort in which all incident cases of Parkinsonism were identified. We randomly matched each case with up to 10 controls from the risk set. Conditional logistic regression was utilized to estimate odds ratio of Parkinsonism associated with metoclopramide use.

Results:

A total of 34,685 patients with diabetes were assembled as the cohort, and 541 incident Parkinsonism cases were identified. There were duration–response and dose–response effects on the risk of developing Parkinsonism. Compared with never-use patients, the adjusted odds ratios (ORs) of continuing therapy for 0–1 month, 1–2 months, 2–3 months, 3–5 months, and more than 5 months were 1.17 [95% confidence interval (CI) 0.93–1.45], 1.44 (95% CI 1.04–2.00), 1.74 (95% CI 1.14–2.65), 1.90 (95% CI 1.23–2.93), and 2.17 (95% CI 1.50–3.12), respectively.

Conclusions:

With metoclopramide treatment, regardless of less or more than 3 months of use, the risk of developing Parkinsonism in patients with newly diagnosed diabetes escalated with the duration of therapy. Therefore, we recommend close monitoring for the development of Parkinsonism in patients treated with metoclopramide, particularly (but not limited to) those with prolonged exposure.

Evidence of Repurposing Drugs and Identifying Contraindications from Real World Study in Parkinson's Disease

There is great unmet need in discovering novel treatment for Parkinson's disease (PD) and identifying the new agents potentially causing drug-induced parkinsonism. New indications and contraindications of drugs are typically approved following rigorous randomized controlled trial (RCT) evaluation. However, RCTs have their inherent limitations, since they are usually conducted in ideal conditions, with high cost and limited follow-up periods. In the past decade, large cohort studies with long follow-up outcome data was derived from a PD database in a real-world setting. Studies based on real world data (RWD) can help to augment and extrapolate data obtained in RCTs and provide information about the safety and effectiveness of a medication in heterogeneous, large populations. In the present review, we focus on the published real world studies designed to develop new treatment strategies for repurposing drugs and identifying contraindications for PD. We also outline the challenges and limitations in these studies. Subsequently we introduce PaWei app platform, which hopefully can facilitate PD management and address real-world problems associated with PD. Better understanding of RWD collection and analysis is needed if RWD is to achieve its full potential.

High exposure compared with standard exposure to metoclopramide associated with a higher risk of parkinsonism: a nationwide population-based cohort study

AIMS

We conducted a cohort study utilizing a nationwide health insurance database to assess the European Medicines Agency's restrictions on using metoclopramide and its association with the risk of parkinsonism.

METHODS

New oral metoclopramide users aged ≥20 years, and age- and gender-matched non-users were recruited between 2001 and 2011. Users were divided into high-exposure (dose >30 mg day^-1 and/or duration >5 days) and standard-exposure (dose ≤30 mg day^-1 and duration ≤5 days) groups. The adjusted hazard ratio (aHR) with 95% confidence interval (CI) estimated the risk of parkinsonism.

RESULTS

During a 1-year period, 122 of 218 931 (0.06%) users of metoclopramide vs. 56 of 218 931 (0.03%) non-users developed parkinsonism (P < 0.001). Among the 122 cases of parkinsonism in users, 64 (0.04%) were from 168 566 standard-exposure users and 58 (0.12%) from 50 365 high-exposure users. Compared with non-users, the risk of parkinsonism was higher in users (aHR 2.16; 95% CI 1.54, 3.02), including standard-exposure (aHR 1.73; 95% CI 1.11, 2.70), and high-exposure (aHR 3.15; 95% CI 1.78, 5.57) users. High-exposure users had a higher risk of parkinsonism than standard-exposure users (aHR 1.83; 95% CI 1.28, 2.63). Within the high-exposure group, 45 233 of 50 365 (89.81%) users and 55 of 58 (94.83%) parkinsonism were from long-duration exposure; 5 132 of 50 365 (10.19%) users and 3 of 58 (5.17%) parkinsonism were from high-dose exposure and long-duration + high-dose exposure.

CONCLUSIONS

The risk of parkinsonism in metoclopramide users, although extremely low (0.06%), is 2.16-fold greater than in non-users. High-exposure users have a 1.83-fold higher risk than standard-exposure users. As users in high-exposure group had a higher risk of parkinsonism than in standard-exposure group, and the majority of users and parkinsonism in high-exposure group were from long-duration exposure; thus, physician are advised to avoid prescribing metoclopramide for >5 days, even if the daily dose is ≤30 mg.