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James E, Ellis C, Brassington R, Sathasivam S, Young CA. Treatment for sialorrhea (excessive saliva) in people with motor neuron disease/amyotrophic lateral sclerosis. Cochrane Database Syst Rev 2022; 5:CD006981. [PMID: 35593746 PMCID: PMC9121913 DOI: 10.1002/14651858.cd006981.pub3] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Motor neuron disease (MND), also known as amyotrophic lateral sclerosis (ALS), is a progressive neurodegenerative condition that may cause dysphagia, as well as limb weakness, dysarthria, emotional lability, and respiratory failure. Since normal salivary production is 0.5 L to 1.5 L daily, loss of salivary clearance due to dysphagia leads to salivary pooling and sialorrhea, often resulting in distress and inconvenience to people with MND. This is an update of a review first published in 2011. OBJECTIVES To assess the effects of treatments for sialorrhea in MND, including medications, radiotherapy and surgery. SEARCH METHODS On 27 August 2021, we searched the Cochrane Neuromuscular Specialised Register, CENTRAL, MEDLINE, Embase, AMED, CINAHL, ClinicalTrials.gov and the WHO ICTRP. We checked the bibliographies of the identified randomized trials and contacted trial authors as needed. We contacted known experts in the field to identify further published and unpublished papers. SELECTION CRITERIA We included randomized controlled trials (RCTs) and quasi-RCTs, including cross-over trials, on any intervention for sialorrhea and related symptoms, compared with each other, placebo or no intervention, in people with ALS/MND. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. MAIN RESULTS We identified four RCTs involving 110 participants with MND who were described as having intractable sialorrhea or bulbar dysfunction. A well-designed study of botulinum toxin B compared to placebo injected into the parotid and submandibular glands of 20 participants showed that botulinum toxin B may produce participant-reported improvement in sialorrhea, but the confidence interval (CI) was also consistent with no effect. Six of nine participants in the botulinum group and two of nine participants in the placebo group reported improvement (risk ratio (RR) 3.00, 95% CI 0.81 to 11.08; 1 RCT; 18 participants; low-certainty evidence). An objective measure indicated that botulinum toxin B probably reduced saliva production (in mL/5 min) at eight weeks compared to placebo (MD -0.50, 95% CI -1.07 to 0.07; 18 participants, moderate-certainty evidence). Botulinum toxin B may have little to no effect on quality of life, measured on the Schedule for Evaluation of Individual Quality of Life direct weighting scale (SEIQoL-DW; 0-100, higher values indicate better quality of life) (MD -2.50, 95% CI -17.34 to 12.34; 1 RCT; 17 participants; low-certainty evidence). The rate of adverse events may be similar with botulinum toxin B and placebo (20 participants; low-certainty evidence). Trialists did not consider any serious events to be related to treatment. A randomized pilot study of botulinum toxin A or radiotherapy in 20 participants, which was at high risk of bias, provided very low-certainty evidence on the primary outcome of the Drool Rating Scale (DRS; range 8 to 39 points, higher scores indicate worse drooling) at 12 weeks (effect size -4.8, 95% CI -10.59 to 0.92; P = 0.09; 1 RCT; 16 participants). Quality of life was not measured. Evidence for adverse events, measured immediately after treatment (RR 7.00, 95% CI 1.04 to 46.95; 20 participants), and after four weeks (when two people in each group had viscous saliva) was also very uncertain. A phase 2, randomized, placebo-controlled cross-over study of 20 mg dextromethorphan hydrobromide and 10 mg quinidine sulfate (DMQ) found that DMQ may produce a participant-reported improvement in sialorrhea, indicated by a slight improvement (decrease) in mean scores for the primary outcome, the Center for Neurologic Study Bulbar Function Scale (CNS-BFS). Mean total CNS-BFS (range 21 (no symptoms) to 112 (maximum symptoms)) was 53.45 (standard error (SE) 1.07) for the DMQ treatment period and 59.31 (SE 1.10) for the placebo period (mean difference) MD -5.85, 95% CI -8.77 to -2.93) with a slight decrease in the CNS-BFS sialorrhea subscale score (range 7 (no symptoms) to 35 (maximum symptoms)) compared to placebo (MD -1.52, 95% CI -2.52 to -0.52) (1 RCT; 60 participants; moderate-certainty evidence). The trial did not report an objective measure of saliva production or measure quality of life. The study was at an unclear risk of bias. Adverse events were similar to other trials of DMQ, and may occur at a similar rate as placebo (moderate-certainty evidence, 60 participants), with the most common side effects being constipation, diarrhea, nausea, and dizziness. Nausea and diarrhea on DMQ treatment resulted in one withdrawal. A randomized, double-blind, placebo-controlled cross-over study of scopolamine (hyoscine), administered using a skin patch, involved 10 randomized participants, of whom eight provided efficacy data. The participants were unrepresentative of clinic cohorts under routine clinical care as they had feeding tubes and tracheostomy ventilation, and the study was at high risk of bias. The trial provided very low-certainty evidence on sialorrhea in the short term (7 days' treatment, measured on the Amyotrophic Lateral Scelerosis Functional Rating Scale-Revised (ALSFRS-R) saliva item (P = 0.572)), and the amount of saliva production in the short term, as indicated by the weight of a cotton roll (P = 0.674), or daily oral suction volume (P = 0.69). Quality of life was not measured. Adverse events evidence was also very uncertain. One person treated with scopolamine had a dry mouth and one died of aspiration pneumonia considered unrelated to treatment. AUTHORS' CONCLUSIONS There is some low-certainty or moderate-certainty evidence for the use of botulinum toxin B injections to salivary glands and moderate-certainty evidence for the use of oral dextromethorphan with quinidine (DMQ) for the treatment of sialorrhea in MND. Evidence on radiotherapy versus botulinum toxin A injections, and scopolamine patches is too uncertain for any conclusions to be drawn. Further research is required on treatments for sialorrhea. Data are needed on the problem of sialorrhea in MND and its measurement, both by participant self-report measures and objective tests. These will allow the development of better RCTs.
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Affiliation(s)
- Eleanor James
- Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Cathy Ellis
- Motor Nerve Clinic, Academic Neurosciences Centre, King's College Hospital, London, UK
| | - Ruth Brassington
- Cochrane Neuromuscular, Queen Square Centre for Neuromuscular Diseases, National Hospital for Neurology and Neurosurgery, London, UK
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Song L, Bekdash R, Morikawa K, Quejada JR, Klein AD, Aina-Badejo D, Yoshida K, Yamamoto HE, Chalan A, Yang R, Patel A, Sirabella D, Lee TM, Joseph LC, Kawano F, Warren JS, Soni RK, Morrow JP, Yazawa M. Sigma non-opioid receptor 1 is a potential therapeutic target for long QT syndrome. NATURE CARDIOVASCULAR RESEARCH 2022; 1:142-156. [PMID: 36051854 PMCID: PMC9431959 DOI: 10.1038/s44161-021-00016-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Some missense gain-of-function mutations in CACNA1C gene, encoding calcium channel CaV1.2, cause a life-threatening form of long QT syndrome named Timothy syndrome, with currently no clinically-effective therapeutics. Here we report that pharmacological targeting of sigma non-opioid intracellular receptor 1 (SIGMAR1) can restore electrophysiological function in iPSC-derived cardiomyocytes generated from patients with Timothy syndrome and two common forms of long QT syndrome, type 1 (LQTS1) and 2 (LQTS2), caused by missense trafficking mutations in potassium channels. Electrophysiological recordings demonstrate that an FDA-approved cough suppressant, dextromethorphan, can be used as an agonist of SIGMAR1, to shorten the prolonged action potential in Timothy syndrome cardiomyocytes and human cellular models of LQTS1 and LQTS2. When tested in vivo, dextromethorphan also normalized the prolonged QT intervals in Timothy syndrome model mice. Overall, our study demonstrates that SIGMAR1 is a potential therapeutic target for Timothy syndrome and possibly other inherited arrhythmias such as LQTS1 and LQTS2.
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3
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Vaughan CL, Bruno V. What neurologists wish palliative care physicians knew. HANDBOOK OF CLINICAL NEUROLOGY 2022; 190:93-104. [PMID: 36055723 DOI: 10.1016/b978-0-323-85029-2.00005-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
As the incidence of neurologic (particularly neurodegenerative) diseases continues to rise, so too will the palliative needs in this patient population. To appropriately care for these patients and families, neurologists and palliative care providers will need to strengthen collaboration. Palliative care providers not formally trained in neurology may feel ill-equipped to manage some of the distinct neuropalliative care needs of these patients. Here, we provide insights into the unique characteristics of patients with neurologic disease and emphasize the relevance of the palliative care skillset in this population to aid the collaboration between palliative care providers and neurologists.
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Affiliation(s)
- Christina L Vaughan
- Department of Neurology and Medicine, Anschutz Medical Center, University of Colorado, Aurora, CO, United States; Department of Neurology, VA Eastern Colorado Health System, Aurora, CO, United States.
| | - Veronica Bruno
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
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Akinbamijo KO, Malmberg IR, Griffith C, Aluko O, Thirumaran R. A Rare Case of Inadvertent Iatrogenic Osmotic Demyelination Syndrome. Cureus 2021; 13:e16180. [PMID: 34367787 PMCID: PMC8336377 DOI: 10.7759/cureus.16180] [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] [Accepted: 07/04/2021] [Indexed: 11/05/2022] Open
Abstract
A 73-year-old African American male presented with altered mental status, severe hyperglycemia, and acute kidney injury. His metabolic derangements including hyperglycemia and hyponatremia were initially thought to be the cause of his encephalopathy. While managing his hyperglycemic hyperosmolar non-ketotic state, he received intravenous rehydration with almost three times his physiologic requirement for normalization of his electrolyte abnormalities. After the correction of the metabolic derangements, he remained confused with dysarthria and labile mood. Magnetic resonance imaging of the brain revealed osmotic demyelination syndrome.
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Hicks AJ, Clay FJ, Ponsford JL, Perry LA, Jayaram M, Batty R, Hopwood M. Pharmacotherapy for the Pseudobulbar Affect in Individuals Who Have Sustained a Traumatic Brain Injury: a Systematic Review. Neuropsychol Rev 2020; 30:28-50. [PMID: 31942705 DOI: 10.1007/s11065-020-09427-7] [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: 08/18/2018] [Accepted: 01/03/2020] [Indexed: 12/11/2022]
Abstract
Pseudobulbar affect is a debilitating condition that significantly reduces quality of life for many individuals following traumatic brain injury (TBI). It is characterized by embarrassing and often uncontrollable episodes of crying or laughter. The aim of this systematic review was to evaluate the effectiveness of pharmacotherapy as compared to all other comparators for the management of pseudobulbar affect in adults who have sustained TBI. Six databases were searched, with additional hand searching of journals, clinical trials registries and international drug regulators to identify published and unpublished studies in English up to June 2018. Studies were eligible for this review if they included adults who had sustained a medically confirmed TBI and presented with pseudobulbar affect. All pharmacotherapy and comparator interventions were considered for inclusion, and study design was not limited to randomised controlled trials. Evidence quality was assessed using Joanna Briggs Institute Critical Appraisal Instruments. Two quasi-experimental studies examining the effectiveness of dextrometamorphan/quinidine (DM/Q) were identified. These studies reported that DM/Q was effective in reducing symptoms of pseudobulbar affect and had a positive safety profile, over follow-up periods of 3 months (n = 87) and 12 months (n = 23). However, both studies were limited by lack of a control group and a high dropout rate. The findings of twelve case reports examining the effectiveness of DM/Q (n = 6) and anti-depressants (n = 6) are also discussed. Further research is required to determine which pharmacological interventions provide the best outcomes for individuals with pseudobulbar affect following TBI, with consideration given to side effect profiles and financial costs.
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Affiliation(s)
- Amelia J Hicks
- Monash-Epworth Rehabilitation Research Centre, Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne, Australia.
| | - Fiona J Clay
- Department of Psychiatry, University of Melbourne, Melbourne, Australia.,Department of Forensic Medicine, Monash University, Southbank, Australia.,Albert Road Clinic, Department of Psychiatry, University of Melbourne, Melbourne, Australia
| | - Jennie L Ponsford
- Monash-Epworth Rehabilitation Research Centre, Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne, Australia
| | - Luke A Perry
- Department of Psychiatry, University of Melbourne, Melbourne, Australia
| | - Mahesh Jayaram
- Department of Psychiatry, University of Melbourne, Melbourne, Australia
| | - Rachel Batty
- Department of Psychiatry, University of Melbourne, Melbourne, Australia
| | - Malcolm Hopwood
- Department of Psychiatry, University of Melbourne, Melbourne, Australia.,Albert Road Clinic, Department of Psychiatry, University of Melbourne, Melbourne, Australia
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Cleymaet S, Nagayoshi K, Gettings E, Faden J. A review and update on the diagnosis and treatment of neuropsychiatric Wilson disease. Expert Rev Neurother 2019; 19:1117-1126. [DOI: 10.1080/14737175.2019.1645009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Sean Cleymaet
- Department of Neurology, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Katsuko Nagayoshi
- Department of Psychiatry, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Edward Gettings
- Department of Neurology, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Justin Faden
- Department of Psychiatry, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
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7
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Finegan E, Chipika RH, Li Hi Shing S, Hardiman O, Bede P. Pathological Crying and Laughing in Motor Neuron Disease: Pathobiology, Screening, Intervention. Front Neurol 2019; 10:260. [PMID: 30949121 PMCID: PMC6438102 DOI: 10.3389/fneur.2019.00260] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 02/26/2019] [Indexed: 12/11/2022] Open
Abstract
Pathological crying and laughing (PCL) has significant quality-of-life implications in amyotrophic lateral sclerosis (ALS); it can provoke restrictive life-style modifications and lead to social isolation. Despite its high prevalence and quality of life implications, it remains surprisingly understudied. Divergent pathophysiological models have been proposed, centered on corticobulbar tract degeneration, prefrontal cortex pathology, sensory deafferentation, and impaired cerebellar gate-control mechanisms. Quantitative MRI techniques and symptom-specific clinical instruments offer unprecedented opportunities to elucidate the anatomical underpinnings of PCL pathogenesis. Emerging neuroimaging studies of ALS support the role of cortico–pontine–cerebellar network dysfunction in context-inappropriate emotional responses. The characterization of PCL-associated pathophysiological processes is indispensable for the development of effective pharmacological therapies.
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Affiliation(s)
- Eoin Finegan
- Computational Neuroimaging Group, Biomedical Sciences Institute, Trinity College Dublin, Dublin, Ireland
| | - Rangariroyashe H Chipika
- Computational Neuroimaging Group, Biomedical Sciences Institute, Trinity College Dublin, Dublin, Ireland
| | - Stacey Li Hi Shing
- Computational Neuroimaging Group, Biomedical Sciences Institute, Trinity College Dublin, Dublin, Ireland
| | - Orla Hardiman
- Computational Neuroimaging Group, Biomedical Sciences Institute, Trinity College Dublin, Dublin, Ireland
| | - Peter Bede
- Computational Neuroimaging Group, Biomedical Sciences Institute, Trinity College Dublin, Dublin, Ireland
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8
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Collina S, Rui M, Stotani S, Bignardi E, Rossi D, Curti D, Giordanetto F, Malacrida A, Scuteri A, Cavaletti G. Are sigma receptor modulators a weapon against multiple sclerosis disease? Future Med Chem 2017; 9:2029-2051. [PMID: 29076758 DOI: 10.4155/fmc-2017-0122] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2023] Open
Abstract
Effective therapies for multiple sclerosis (MS) are still missing. This neurological disease affects more than 2.5 million people worldwide. To date, biological immunomodulatory drugs are effective and safe during short-term treatment, but they are suitable only for parenteral administration and they are expensive. Accordingly, academic and industrial environments are still focusing their efforts toward the development of new MS drugs. Considering that neurodegeneration is a contributory factor in the onset of MS, herein we will focus on the crucial role played by sigma 1 receptors (S1Rs) in MS. A pilot study was performed, evaluating the effect of the S1R agonist (R)-RC33 on rat dorsal root ganglia experimental model. The encouraging results support the potential of S1R agonists for MS treatment.
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Affiliation(s)
- Simona Collina
- Department of Drug Sciences, Medicinal Chemistry & Pharmaceutical Technology Section, Centre for Health Technologies (CHT), University of Pavia, Viale Taramelli 12, Pavia 27100, Italy
| | - Marta Rui
- Department of Drug Sciences, Medicinal Chemistry & Pharmaceutical Technology Section, Centre for Health Technologies (CHT), University of Pavia, Viale Taramelli 12, Pavia 27100, Italy
| | - Silvia Stotani
- Medicinal Chemistry, Taros Chemicals GmbH & Co. KG, Emil-Figge-Str. 76a, Dortmund 44227, Germany
| | - Emanuele Bignardi
- Department of Drug Sciences, Medicinal Chemistry & Pharmaceutical Technology Section, Centre for Health Technologies (CHT), University of Pavia, Viale Taramelli 12, Pavia 27100, Italy
| | - Daniela Rossi
- Department of Drug Sciences, Medicinal Chemistry & Pharmaceutical Technology Section, Centre for Health Technologies (CHT), University of Pavia, Viale Taramelli 12, Pavia 27100, Italy
| | - Daniela Curti
- Department of Biology & Biotechnology 'L. Spallanzani', Laboratory of Cellular & Molecular Neuropharmacology, University of Pavia, Via Ferrata 9, Pavia 27100, Italy
| | | | - Alessio Malacrida
- Experimental Neurology Unit, Department of Medicine & Surgery & Milan Center for Neuroscience, University of Milan Bicocca, Via Cadore 48, Monza 20900, Italy
| | - Arianna Scuteri
- Experimental Neurology Unit, Department of Medicine & Surgery & Milan Center for Neuroscience, University of Milan Bicocca, Via Cadore 48, Monza 20900, Italy
| | - Guido Cavaletti
- Experimental Neurology Unit, Department of Medicine & Surgery & Milan Center for Neuroscience, University of Milan Bicocca, Via Cadore 48, Monza 20900, Italy
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10
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Perotti LP, Cummings LD, Mercado J. Behavioral Treatment of Pseudobulbar Affect: A Case Report. Perspect Psychiatr Care 2016; 52:82-7. [PMID: 27091117 DOI: 10.1111/ppc.12159] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Revised: 01/08/2016] [Accepted: 01/30/2016] [Indexed: 12/11/2022] Open
Abstract
PURPOSE To determine if it is possible to successfully treat pseudobulbar affect (PBA) using a behavioral approach. DESIGN AND METHODS Two experiments were conducted, each a double reversal design with the same single subject in both. The first experiment tested the hypothesis that the rate of PBA could be controlled by manipulation of its consequences. The second experiment tested the hypothesis that use of a self-control procedure would control the rate of PBA. FINDINGS Rate of PBA could not be controlled by consequence manipulation, but rate of PBA could be controlled through use of a self-control procedure. PRACTICE IMPLICATIONS Pending confirmatory research, behavioral interventions utilizing self-control procedures should be considered in patients with PBA.
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Affiliation(s)
- Laurence P Perotti
- Clinical Psychologist at the Multidisciplinary Clinic, Department of Behavioral Medicine, Brooke Army Medical Center, San Antonio, Texas, USA
| | - Latiba D Cummings
- Physician Assistant in Brain Injury Rehabilitation Service, Department of Orthopedics, Brooke Army Medical Center, San Antonio, Texas, USA
| | - Janyna Mercado
- Neuropsychologist in Neuropsychology Service, Department of Behavioral Medicine, Brooke Army Medical Center, San Antonio, Texas, USA
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Thapliyal N, Patel H, Karpoormath R, Goyal RN, Patel R. A categorical review on electroanalytical determination of non-narcotic over-the-counter abused antitussive drugs. Talanta 2015; 142:157-63. [DOI: 10.1016/j.talanta.2015.04.061] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Revised: 04/20/2015] [Accepted: 04/21/2015] [Indexed: 10/23/2022]
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12
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Affiliation(s)
- Marian W Roman
- a University of Tennessee , College of Nursing , Knoxville , Tennessee , USA
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Lisak RP, Nedelkoska L, Benjamins JA. Effects of dextromethorphan on glial cell function: Proliferation, maturation, and protection from cytotoxic molecules. Glia 2014; 62:751-62. [DOI: 10.1002/glia.22639] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2013] [Revised: 01/20/2014] [Accepted: 01/22/2014] [Indexed: 12/11/2022]
Affiliation(s)
- Robert P. Lisak
- Department of Neurology; Wayne State University School of Medicine; Detroit Missouri
- Department of Immunology/Microbiology; Wayne State University School of Medicine; Detroit Missouri
| | - Liljana Nedelkoska
- Department of Neurology; Wayne State University School of Medicine; Detroit Missouri
| | - Joyce A. Benjamins
- Department of Neurology; Wayne State University School of Medicine; Detroit Missouri
- Department of Immunology/Microbiology; Wayne State University School of Medicine; Detroit Missouri
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Toosy A, Ciccarelli O, Thompson A. Symptomatic treatment and management of multiple sclerosis. HANDBOOK OF CLINICAL NEUROLOGY 2014; 122:513-562. [PMID: 24507534 DOI: 10.1016/b978-0-444-52001-2.00023-6] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
The range of symptoms which occur in multiple sclerosis (MS) can have disabling functional consequences for patients and lead to significant reductions in their quality of life. MS symptoms can also interact with each other, making their management challenging. Clinical trials aimed at identifying symptomatic therapies have generally been poorly designed and have tended to be underpowered. Therefore, the evidence base for the management of MS symptoms with pharmacologic therapies is not strong and tends to rely upon open-label studies, case reports, and clinical trials with small numbers of patients and poorly validated clinical outcome measures. Recently, there has been a growing interest in the management of MS symptoms with pharmacologic treatments, and better-designed, randomized, double-blind, controlled trials have been reported. This chapter will describe the evidence base predominantly behind the various pharmacologic approaches to the management of MS symptoms, which in most, if not all, cases, requires multidisciplinary input. Drugs routinely recommended for individual symptoms and new therapies, which are currently in the development pipeline, will be reviewed. More interventional therapies related to symptoms that are refractory to pharmacotherapy will also be discussed, where relevant.
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Affiliation(s)
- Ahmed Toosy
- Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, Queen Square, London, UK
| | - Olga Ciccarelli
- Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, Queen Square, London, UK
| | - Alan Thompson
- Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, Queen Square, London, UK.
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Schoedel KA, Morrow SA, Sellers EM. Evaluating the safety and efficacy of dextromethorphan/quinidine in the treatment of pseudobulbar affect. Neuropsychiatr Dis Treat 2014; 10:1161-74. [PMID: 25061302 PMCID: PMC4079824 DOI: 10.2147/ndt.s30713] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Pseudobulbar affect (PBA) is a common manifestation of brain pathology associated with many neurological diseases, including amyotrophic lateral sclerosis, Alzheimer's disease, stroke, multiple sclerosis, Parkinson's disease, and traumatic brain injury. PBA is defined by involuntary and uncontrollable expressed emotion that is exaggerated and inappropriate, and also incongruent with the underlying emotional state. Dextromethorphan/quinidine (DM/Q) is a combination product indicated for the treatment of PBA. The quinidine component of DM/Q inhibits the cytochrome P450 2D6-mediated metabolic conversion of dextromethorphan to its active metabolite dextrorphan, thereby increasing dextromethorphan systemic bioavailability and driving the pharmacology toward that of the parent drug and away from adverse effects of the dextrorphan metabolite. Three published efficacy and safety studies support the use of DM/Q in the treatment of PBA; significant effects were seen on the primary end point, the Center for Neurologic Study-Lability Scale, as well as secondary efficacy end points and quality of life. While concentration-effect relationships appear relatively weak for efficacy parameters, concentrations of DM/Q may have an impact on safety. Some special safety concerns exist with DM/Q, primarily because of the drug interaction and QT prolongation potential of the quinidine component. However, because concentrations of dextrorphan (which is responsible for many of the parent drug's side effects) and quinidine are lower than those observed in clinical practice with these drugs administered alone, some of the perceived safety issues may not be as relevant with this low dose combination product. However, since patients with PBA have a variety of other medical problems and are on numerous other medications, they may not tolerate DM/Q adverse effects, or may be at risk for drug interactions. Some caution is warranted when initiating DM/Q treatment, particularly in patients with underlying risk factors for torsade de pointes and in those receiving medications that may interact with DM/Q.
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Affiliation(s)
| | | | - Edward M Sellers
- DL Global Partners, Inc., Toronto, Canada ; University of Toronto, Toronto, Ontario, Canada
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King RR, Reiss JP. The epidemiology and pathophysiology of pseudobulbar affect and its association with neurodegeneration. Degener Neurol Neuromuscul Dis 2013; 3:23-31. [PMID: 30890891 PMCID: PMC6065587 DOI: 10.2147/dnnd.s34160] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Pseudobulbar affect is a disorder resulting from neurologic damage manifesting as sudden, stereotyped affective outbursts that are not reflective of internal emotion. A literature review was completed to examine the current understanding of the epidemiology, characterization, diagnosis, pathophysiology, and treatment of pseudobulbar affect. This review revealed that it is common in neurodegenerative disorders but is poorly recognized, placing significant impacts on patients and their families. The disorder appears to result from a disruption of the cortico-limbic-subcortical-thalamic-pontocerebellar network involved in emotional expression and regulation with resulting disruptions of neurotransmitter systems. Effective treatment is available with agents such as selective serotonin reuptake inhibitors and dextromethorphan combined with quinidine, but further well-designed comparative studies are needed. Advances in technology such as neuroimaging may enhance knowledge about the pathophysiology of this disorder, and help guide future interventions.
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Affiliation(s)
- Rebecca R King
- Department of Psychiatry, University of Western Ontario, London Health Sciences Centre, Victoria Hospital, London, Ontario, Canada,
| | - Jeffrey P Reiss
- Department of Psychiatry, University of Western Ontario, London Health Sciences Centre, Victoria Hospital, London, Ontario, Canada,
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Kourrich S, Su TP, Fujimoto M, Bonci A. The sigma-1 receptor: roles in neuronal plasticity and disease. Trends Neurosci 2012; 35:762-71. [PMID: 23102998 PMCID: PMC3587126 DOI: 10.1016/j.tins.2012.09.007] [Citation(s) in RCA: 181] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2012] [Revised: 08/14/2012] [Accepted: 09/20/2012] [Indexed: 12/31/2022]
Abstract
Sigma-1 receptors (Sig-1Rs) have been implicated in many neurological and psychiatric conditions. Sig-1Rs are intracellular chaperones that reside specifically at the endoplasmic reticulum (ER)-mitochondrion interface, referred to as the mitochondrion-associated ER membrane (MAM). Here, Sig-1Rs regulate ER-mitochondrion Ca(2+) signaling. In this review, we discuss the current understanding of Sig-1R functions. Based on this, we suggest that the key cellular mechanisms linking Sig-1Rs to neurological disorders involve the translocation of Sig-1Rs from the MAM to other parts of the cell, whereby Sig-1Rs bind and modulate the activities of various ion channels, receptors, or kinases. Thus, Sig-1Rs and their associated ligands may represent new avenues for treating aspects of neurological and psychiatric diseases.
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Affiliation(s)
- Saïd Kourrich
- Synaptic Plasticity Section, Intramural Research Program, National Institute on Drug Abuse (NIDA), National Institutes of Health (NIH), Department of Health and Human Services (DHHS), Baltimore, MD, USA
| | - Tsung-Ping Su
- Cellular Pathobiology Section, Intramural Research Program, NIDA, NIH, DHHS, Baltimore, MD USA
| | - Michiko Fujimoto
- Cellular Pathobiology Section, Intramural Research Program, NIDA, NIH, DHHS, Baltimore, MD USA
| | - Antonello Bonci
- Synaptic Plasticity Section, Intramural Research Program, National Institute on Drug Abuse (NIDA), National Institutes of Health (NIH), Department of Health and Human Services (DHHS), Baltimore, MD, USA
- Department of Neurology, University of California, San Francisco, CA, USA
- Solomon H. Snyder Neuroscience Institute, Johns Hopkins University School of Medicine, Baltimore, CA, USA
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Daly JP, Caplan JP. A Naturalistic On-Off-On Trial of Dextromethorphan/Quinidine for Agitation Associated with Cerebellar Injury. PSYCHOSOMATICS 2012; 53:470-3. [DOI: 10.1016/j.psym.2011.11.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/15/2011] [Revised: 10/03/2011] [Accepted: 10/04/2011] [Indexed: 12/14/2022]
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Logan BK, Yeakel JK, Goldfogel G, Frost MP, Sandstrom G, Wickham DJ. Dextromethorphan Abuse Leading to Assault, Suicide, or Homicide. J Forensic Sci 2012; 57:1388-94. [DOI: 10.1111/j.1556-4029.2012.02133.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Work SS, Colamonico JA, Bradley WG, Kaye RE. Pseudobulbar affect: an under-recognized and under-treated neurological disorder. Adv Ther 2011; 28:586-601. [PMID: 21660634 DOI: 10.1007/s12325-011-0031-3] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2011] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Pseudobulbar affect (PBA) is a neurologic syndrome of emotional affect disinhibition, characterized by uncontrollable, exaggerated, and often inappropriate emotional outbursts, which may cause severe distress, embarrassment, and social dysfunction. However, the US prevalence of PBA remains unknown. METHODS An online survey was conducted primarily to estimate the US prevalence of PBA in patients with the six most commonly associated conditions: Alzheimer's disease, amyotrophic lateral sclerosis, multiple sclerosis, Parkinson's disease, stroke, and traumatic brain injury. Invitations to participate were randomly sent online to adults (aged ≥ 18 years) registered in the Harris Poll Online Panel who were patients or belonged to a household with a patient diagnosed with one of the six conditions (identified through previous screening by Harris Interactive). Participants were screened for PBA using the Pathological Laughing and Crying Scale (PLACS) and the Center for Neurologic Study-Lability Scale (CNS-LS). PBA estimates were made using a cut-off score of ≥ 13 on the PLACS and two different cut-off thresholds on the CNS-LS, a lower one of ≥ 13 and a more rigorous one of ≥ 21. Existing US prevalence data for the six underlying conditions were used to estimate US prevalence of PBA. RESULTS Of 38,000 individuals invited to participate, 8876 responded (23%) and 2318 (26%) completed the questionnaire. Mean prevalence of PBA across all six conditions was 10.1%, 9.4%, and 37.5% with the PLACS ≥ 13, CNS-LS ≥ 21, and CNS-LS ≥ 13 thresholds, respectively. Using disease population estimates from government agencies and professional organizations, the estimated US population with PBA ranged from 1.8 to 7.1 million. Among patients who discussed their laughing and/or crying episodes with a physician, 41% were diagnosed, and about half received a medication for their episodes. CONCLUSIONS The overall prevalence of PBA was estimated to be about 10% across these commonly associated underlying neurological conditions and appears to be under-recognized.
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Affiliation(s)
- Susan S Work
- Avanir Pharmaceuticals, Inc., 101 Enterprise, Suite 300, Aliso Viejo, CA, 92656, USA.
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Hayashi T, Tsai SY, Mori T, Fujimoto M, Su TP. Targeting ligand-operated chaperone sigma-1 receptors in the treatment of neuropsychiatric disorders. Expert Opin Ther Targets 2011; 15:557-77. [PMID: 21375464 PMCID: PMC3076924 DOI: 10.1517/14728222.2011.560837] [Citation(s) in RCA: 169] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Current drugs for the treatment of psychiatric or neurodegenerative disorders have limitations. Psychotherapeutic drugs such as typical and atypical antipsychotics, tricyclic antidepressants and selective monoamine reuptake inhibitors, aim to normalize the hyper- or hypo-neurotransmission of monoaminergic systems. Despite their contribution to the outcomes of psychiatric patients, these agents often exert severe side effects and require chronic treatments to promote amelioration of symptoms. Drugs available for the treatment of neurodegenerative disorders are severely limited. AREAS COVERED Recent evidence that has shed light on sigma-1 receptor ligands, which may serve as a new class of antidepressants or neuroprotective agents. Sigma-1 receptors are novel ligand-operated molecular chaperones regulating signal transduction, ER stress, cellular redox, cellular survival and synaptogenesis. Selective sigma-1 receptor ligands exert rapid antidepressant-like, anxiolytic, antinociceptive and robust neuroprotective actions in preclinical studies. Recent studies that suggest that reactive oxygen species might play a role as signal integrators downstream of Sig-1Rs are also covered. EXPERT OPINION The advances in sigma receptor research in the last decade have begun to elucidate the intracellular signal cascades upstream and downstream of sigma-1 receptors. The novel ligand-operated properties of the sigma-1 receptor chaperone may enable interventions by which stress-related cellular systems can be pharmacologically controlled.
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Affiliation(s)
- Teruo Hayashi
- National Institute on Drug Abuse, National Institutes of Health-Cellular Stress Signaling Unit, Integrative Neuroscience Branch, Baltimore, MD 21224, USA.
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Abstract
Pseudobulbar affect is characterized by uncontrollable, inappropriate laughing and/or crying that is either unrelated or out of proportion to the emotions felt by the patient and occurs in patients with neurological disorders, such as amyotrophic lateral sclerosis (ALS), multiple sclerosis or traumatic brain injury. Dextromethorphan/quinidine is indicated in the US for the treatment of pseudobulbar affect. Dextromethorphan, when its metabolism is inhibited by the coadministration of quinidine, has been shown to have a positive effect on the symptoms of pseudobulbar affect. Dextromethorphan/quinidine 20 mg/10 mg twice daily was associated with a significantly greater decrease in the rate of pseudobulbar affect episodes per day (primary endpoint) than placebo in the 12-week, randomized, double-blind, placebo-controlled, multicentre STAR trial (Safety, Tolerability, And efficacy Results trial of AVP-923 in PBA [pseudobulbar affect]) involving patients with pseudobulbar affect and ALS or multiple sclerosis. Moreover, the mean change from baseline in Center for Neurologic Study-Lability Scale score at 12 weeks was significantly greater among recipients of dextromethorphan/quinidine 20 mg/10 mg twice daily than those receiving placebo. Dextromethorphan/quinidine 20 mg/10 mg twice daily was generally well tolerated. The drug has been shown to cause dosage-dependent corrected QT interval (QTc) prolongation; however, in the STAR trial, dextromethorphan/quinidine 20 mg/10 mg twice daily appeared to be well tolerated with regard to QTc prolongation.
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Moving toward a predictive and personalized clinical approach in amyotrophic lateral sclerosis: novel developments and future directions in diagnosis, genetics, pathogenesis and therapies. EPMA J 2010. [PMID: 23199068 PMCID: PMC3405327 DOI: 10.1007/s13167-010-0027-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Amyotrophic lateral sclerosis (ALS) is a rare neurodegenerative disease that affects upper and lower motor neurons in the brain and spinal cord, with progressive weakness and atrophy of most muscles in the body and is almost always fatal within 3–5 years. A small proportion of cases are familial, and remarkable achievements have been made during the last years in understanding the genetics of the disease. In spite of this, the basic pathogenic mechanisms underlying the sporadic disease are still poorly understood. There is urgent need for better understanding of the pathogenic processes in order to be able to develop effective treatments. The present review will focus on recent knowledge gained in diagnosis, genetics, pathogenesis and therapies in ALS. Future development of diagnostic technologies integrating genetic, environmental and individual information will enable us to predict a population at risk for ALS. New treatments actually in development will help improve the medical management of ALS patients, taking into consideration individual traits, as genetic background, and pave a way for a more effective personalized diagnostic and treatment approach.
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