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Liu Z, Lin S, Zhou J, Wang X, Wang Z, Yang Y, Ma H, Chen Z, Ren K, Wu L, Zhuang H, Ling Y, Feng T. Machine-learning model for the prediction of acute orthostatic hypotension after levodopa administration. CNS Neurosci Ther 2024; 30:e14575. [PMID: 38467597 PMCID: PMC10927600 DOI: 10.1111/cns.14575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 11/11/2023] [Accepted: 12/06/2023] [Indexed: 03/13/2024] Open
Abstract
BACKGROUND Levodopa could induce orthostatic hypotension (OH) in Parkinson's disease (PD) patients. Accurate prediction of acute OH post levodopa (AOHPL) is important for rational drug use in PD patients. Here, we develop and validate a prediction model of AOHPL to facilitate physicians in identifying patients at higher probability of developing AOHPL. METHODS The study involved 497 PD inpatients who underwent a levodopa challenge test (LCT) and the supine-to-standing test (STS) four times during LCT. Patients were divided into two groups based on whether OH occurred during levodopa effectiveness (AOHPL) or not (non-AOHPL). The dataset was randomly split into training (80%) and independent test data (20%). Several models were trained and compared for discrimination between AOHPL and non-AOHPL. Final model was evaluated on independent test data. Shapley additive explanations (SHAP) values were employed to reveal how variables explain specific predictions for given observations in the independent test data. RESULTS We included 180 PD patients without AOHPL and 194 PD patients with AOHPL to develop and validate predictive models. Random Forest was selected as our final model as its leave-one-out cross validation performance [AUC_ROC 0.776, accuracy 73.6%, sensitivity 71.6%, specificity 75.7%] outperformed other models. The most crucial features in this predictive model were the maximal SBP drop and DBP drop of STS before medication (ΔSBP/ΔDBP). We achieved a prediction accuracy of 72% on independent test data. ΔSBP, ΔDBP, and standing mean artery pressure were the top three variables that contributed most to the predictions across all individual observations in the independent test data. CONCLUSIONS The validated classifier could serve as a valuable tool for clinicians, offering the probability of a patient developing AOHPL at an early stage. This supports clinical decision-making, potentially enhancing the quality of life for PD patients.
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Affiliation(s)
- Zhu Liu
- Department of Neurology, Center for Movement Disorders, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesBeijingChina
| | - Shinuan Lin
- GYENNO SCIENCE CO., LTD.ShenzhenChina
- HUST – GYENNO CNS Intelligent Digital Medicine Technology CenterWuhanChina
| | - Junhong Zhou
- Hinda and Arthur Marcus Institute for Aging ResearchHebrew SeniorLifeRoslindaleMassachusettsUSA
- Harvard Medical SchoolBostonMassachusettsUSA
| | - Xuemei Wang
- Department of Neurology, Center for Movement Disorders, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesBeijingChina
| | - Zhan Wang
- Department of Neurology, Center for Movement Disorders, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesBeijingChina
| | - Yaqin Yang
- Department of Neurology, Center for Movement Disorders, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesBeijingChina
| | - Huizi Ma
- Department of Neurology, Center for Movement Disorders, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesBeijingChina
| | - Zhonglue Chen
- GYENNO SCIENCE CO., LTD.ShenzhenChina
- HUST – GYENNO CNS Intelligent Digital Medicine Technology CenterWuhanChina
| | - Kang Ren
- GYENNO SCIENCE CO., LTD.ShenzhenChina
- HUST – GYENNO CNS Intelligent Digital Medicine Technology CenterWuhanChina
| | - Lingyu Wu
- GYENNO SCIENCE CO., LTD.ShenzhenChina
- HUST – GYENNO CNS Intelligent Digital Medicine Technology CenterWuhanChina
| | - Haimei Zhuang
- GYENNO SCIENCE CO., LTD.ShenzhenChina
- HUST – GYENNO CNS Intelligent Digital Medicine Technology CenterWuhanChina
| | - Yun Ling
- GYENNO SCIENCE CO., LTD.ShenzhenChina
- HUST – GYENNO CNS Intelligent Digital Medicine Technology CenterWuhanChina
| | - Tao Feng
- Department of Neurology, Center for Movement Disorders, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesBeijingChina
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Liu Z, Su D, Zhou J, Wang X, Wang Z, Yang Y, Ma H, Feng T. Acute effect of levodopa on orthostatic hypotension and its association with motor responsiveness in Parkinson's disease: Results of acute levodopa challenge test. Parkinsonism Relat Disord 2023; 115:105860. [PMID: 37742502 DOI: 10.1016/j.parkreldis.2023.105860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Revised: 09/15/2023] [Accepted: 09/17/2023] [Indexed: 09/26/2023]
Abstract
OBJECTIVE Levodopa administration can induce or worsen orthostatic hypotension (OH) in patients with Parkinson's disease (PD). Understanding of acute OH post levodopa (AOHPL) is important for rational drug use in PD patients. Primary objective of this study was to investigate the incidence of AOHPL in PD patients. The secondary objectives were a) hemodynamic character of AOHPL; b) risk factors of AOHPL; c) relationship between motor responsiveness and blood pressure (BP) change. METHODS 490 PD inpatients underwent acute levodopa challenge test (LCT). Supine-to-standing test (STS) was done 4 times during LCT, including before levodopa and every hour post levodopa intake within 3 h. Patients were classified into two groups, AOHPL and non-AOHPL. A comprehensive set of clinical features scales was assessed, including both motor (e.g., motor response, wearing-off) and nonmotor symptoms (e.g., autonomic dysfunction, neuropsychology). RESULTS 33.1% PD patients had OH before drug, 50.8% the same subjects had AOHPL during levodopa effectiveness. PD patients who had better response to levodopa likely to have lower standing mean artery pressure (MAP) and severer systolic BP drop after levodopa intake. BP increased when the motor performance worsened and vice versa. Beneficial response was a risk factors of AOHPL (OR = 1.624, P = 0.017). CONCLUSIONS AOHPL was very common in PD patients. We suggested that PD patients with risk factors should monitor hemodynamic change during LCT to avoid AOHPL following the introduction or increase of oral levodopa. The fluctuations of BP were complicated and multifactorial, likely caused by the process of PD and levodopa both.
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Affiliation(s)
- Zhu Liu
- Center for Movement Disorders, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Dongning Su
- Center for Movement Disorders, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Junhong Zhou
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Roslindale, MA, United States; Harvard Medical School, Boston, MA, United States
| | - Xuemei Wang
- Center for Movement Disorders, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Zhan Wang
- Center for Movement Disorders, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yaqin Yang
- Center for Movement Disorders, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Huizi Ma
- Center for Movement Disorders, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Tao Feng
- Center for Movement Disorders, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China.
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Zhu S, Li H, Xu X, Luo Y, Deng B, Guo X, Guo Y, Yang W, Wei X, Wang Q. The Pathogenesis and Treatment of Cardiovascular Autonomic Dysfunction in Parkinson's Disease: What We Know and Where to Go. Aging Dis 2021; 12:1675-1692. [PMID: 34631214 PMCID: PMC8460297 DOI: 10.14336/ad.2021.0214] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Accepted: 02/14/2021] [Indexed: 12/15/2022] Open
Abstract
Cardiovascular autonomic dysfunctions (CAD) are prevalent in Parkinson’s disease (PD). It contributes to the development of cognitive dysfunction, falls and even mortality. Significant progress has been achieved in the last decade. However, the underlying mechanisms and effective treatments for CAD have not been established yet. This review aims to help clinicians to better understand the pathogenesis and therapeutic strategies. The literatures about CAD in patients with PD were reviewed. References for this review were identified by searches of PubMed between 1972 and March 2021, with the search term “cardiovascular autonomic dysfunctions, postural hypotension, orthostatic hypotension (OH), supine hypertension (SH), postprandial hypotension, and nondipping”. The pathogenesis, including the neurogenic and non-neurogenic mechanisms, and the current pharmaceutical and non-pharmaceutical treatment for CAD, were analyzed. CAD mainly includes four aspects, which are OH, SH, postprandial hypotension and nondipping, among them, OH is the main component. Both non-neurogenic and neurogenic mechanisms are involved in CAD. Failure of the baroreflex circulate, which includes the lesions at the afferent, efferent or central components, is an important pathogenesis of CAD. Both non-pharmacological and pharmacological treatment alleviate CAD-related symptoms by acting on the baroreflex reflex circulate. However, pharmacological strategy has the limitation of failing to enhance baroreflex sensitivity and life quality. Novel OH treatment drugs, such as pyridostigmine and atomoxetine, can effectively improve OH-related symptoms via enhancing residual sympathetic tone, without adverse reactions of supine hypertension. Baroreflex impairment is a crucial pathological mechanism associated with CAD in PD. Currently, non-pharmacological strategy was the preferred option for its advantage of enhancing baroreflex sensitivity. Pharmacological treatment is a second-line option. Therefore, to find drugs that can enhance baroreflex sensitivity, especially via acting on its central components, is urgently needed in the scientific research and clinical practice.
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Affiliation(s)
- Shuzhen Zhu
- Department of Neurology, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Hualing Li
- Department of Neurology, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Xiaoyan Xu
- Department of Neurology, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Yuqi Luo
- Department of Neurology, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Bin Deng
- Department of Neurology, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Xingfang Guo
- Department of Neurology, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Yang Guo
- Department of Neurology, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Wucheng Yang
- Department of Neurology, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Xiaobo Wei
- Department of Neurology, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Qing Wang
- Department of Neurology, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong, China
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Klanbut S, Phattanarudee S, Wongwiwatthananukit S, Suthisisang C, Bhidayasiri R. Symptomatic orthostatic hypotension in Parkinson's disease patients: Prevalence, associated factors and its impact on balance confidence. J Neurol Sci 2017; 385:168-174. [PMID: 29406900 DOI: 10.1016/j.jns.2017.12.037] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Revised: 12/26/2017] [Accepted: 12/28/2017] [Indexed: 01/17/2023]
Abstract
BACKGROUND Orthostatic hypotension (OH) is a commonly reported sign of the cardiovascular autonomic dysfunctions associated with Parkinson's disease (PD). Patients might suffer from a variety of the clinical symptoms of OH, including dizziness, lightheadedness, or problems with vision and fatigue. OBJECTIVES To determine the prevalence of, and factors associated with, symptomatic orthostatic hypotension (OH) in Parkinson's disease (PD) and to identify any relationships between the clinical symptoms of OH and balance confidence in this patient population. METHODS Symptomatic OH was defined as a systolic or diastolic BP fall of ≥20 or ≥10mmHg respectively, within 3min of standing and an Orthostatic Hypotension Questionnaire (OHQ) score of more than zero. Factors related to symptomatic OH were identified from a multivariate logistic regression analysis. Pearson's correlation test was used to reveal any relationships between the clinical symptoms of OH and a patient's confidence in their ability to balance, assessed using the Activities-specific Balance Confidence (ABC) scale. RESULTS 100 Thai PD patients were consecutively recruited into this study. The prevalence of symptomatic OH was 18%, asymptomatic OH was 4%, while 78% were patients without OH. Factors associated with symptomatic OH were age (OR, 95%CI: 1.06, 1.003-1.115, p=0.038) and hypertension (OR, 95%CI: 6.16, 1.171-32.440, p=0.032). A significant and negative correlation (r=-0.229, p=0.022) between OHQ composite scores and item 3 of the ABC scale (picking up slippers from floor), one of the movements in a vertical orientation, was found. CONCLUSION Elderly PD patients and with a co-morbidity of essential hypertension should be closely evaluated for the presence of symptomatic OH. In addition, they should be advised to change positions slowly, especially those in a vertical orientation.
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Affiliation(s)
- Siranan Klanbut
- Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Chulalongkorn University, Bangkok, Thailand
| | - Siripan Phattanarudee
- Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Chulalongkorn University, Bangkok, Thailand.
| | | | | | - Roongroj Bhidayasiri
- Chulalongkorn Center of Excellence for Parkinson's Disease and Related Disorders, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
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Bacchi S, Chim I, Kramer P, Postuma RB. Domperidone for Hypotension in Parkinson’s Disease: A Systematic Review. JOURNAL OF PARKINSONS DISEASE 2017; 7:603-617. [DOI: 10.3233/jpd-171209] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
| | - Ivana Chim
- University of Adelaide, Adelaide, SA, Australia
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Pathak A, Senard JM. Blood pressure disorders during Parkinson’s disease: epidemiology, pathophysiology and management. Expert Rev Neurother 2014; 6:1173-80. [PMID: 16893345 DOI: 10.1586/14737175.6.8.1173] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Blood pressure disorders are highly prevalent in the course of Parkinson's disease (PD). They relate to autonomic failure and are frequently associated with orthostatic hypotension, postprandial hypotension and supine hypertension. Supine hypertension, which may concern up to 50% of patients with PD and autonomic failure, is driven by residual sympathetic activity and changes in sensitivity of vascular adrenergic receptors. It can also be induced or worsened by antihypotensive drugs. Even if little data is available, a set of arguments suggests that supine hypertension sometimes requires treatment. This review will focus on recent data on the pathophysiology and the management of supine hypertension in the context of its association with orthostatic hypotension.
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Affiliation(s)
- Atul Pathak
- Laboratoire de Pharmacologie Médicale et Clinique, Inserm U586, Unité de recherche sur les Obésités, Toulouse F-31432 France.
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Sánchez-Ferro A, Benito-León J, Gómez-Esteban JC. The management of orthostatic hypotension in Parkinson's disease. Front Neurol 2013; 4:64. [PMID: 23772219 PMCID: PMC3677136 DOI: 10.3389/fneur.2013.00064] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2013] [Accepted: 05/19/2013] [Indexed: 12/23/2022] Open
Abstract
Orthostatic hypotension (OH) is a common and disabling symptom affecting Parkinson's disease (PD) patients. We present the effect of the different therapies commonly used to manage PD on this clinical manifestation. For this purpose, we describe the relationship between OH and the current treatments employed in PD, such as L-DOPA, dopaminergic agonists, and continuous dopaminergic stimulation therapies. Additionally, we review the therapeutic measures that could be used to ameliorate OH. There are different approaches to deal with this manifestation, including pharmacological and non-pharmacological treatments, although none of them is specifically aimed for treating OH in PD.
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Affiliation(s)
- Alvaro Sánchez-Ferro
- Department of Neurology, University Hospital "12 de Octubre," Madrid , Spain ; Department of Medicine, Faculty of Medicine, Complutense University , Madrid , Spain ; Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas , Madrid , Spain ; Instituto de Salud Carlos III , Madrid , Spain
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8
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Prevalence of orthostatic hypotension in Parkinson's disease: a systematic review and meta-analysis. Parkinsonism Relat Disord 2011; 17:724-9. [PMID: 21571570 DOI: 10.1016/j.parkreldis.2011.04.016] [Citation(s) in RCA: 221] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2010] [Revised: 04/16/2011] [Accepted: 04/23/2011] [Indexed: 11/21/2022]
Abstract
BACKGROUND Although orthostatic hypotension (OH) is recognized as one of the main non-motor symptoms of Parkinson's disease (PD), there is inconsistent evidence about the prevalence of OH in PD. To estimate the prevalence of OH in PD more precisely we conducted a systematic review of the literature. METHODS From PubMed and Embase searches with predefined inclusion criteria, we identified studies published up till December 2009. Prevalence numbers from studies were pooled using a non-linear random-effects meta-analysis. RESULTS We found 25 studies from which the prevalence of OH could be calculated. The pooled estimate of the point prevalence of OH in PD was 30.1% (95% CI: 22.9% to 38.4%). We found a large statistical heterogeneity between studies which could not be reduced by several subgroup analyses. CONCLUSIONS The estimated prevalence of OH in PD is 30%. However, due to the large heterogeneity between studies this pooled estimate should be interpreted with caution. More data from unselected population-based cohorts are needed.
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Pavy-Le Traon A, Amarenco G, Duerr S, Kaufmann H, Lahrmann H, Shaftman SR, Tison F, Wenning GK, Goetz CG, Poewe W, Sampaio C, Schrag A, Stebbins GT, Rascol O. The Movement Disorders task force review of dysautonomia rating scales in Parkinson's disease with regard to symptoms of orthostatic hypotension. Mov Disord 2011; 26:1985-92. [PMID: 21547951 DOI: 10.1002/mds.23742] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2009] [Revised: 03/09/2011] [Accepted: 03/11/2011] [Indexed: 02/05/2023] Open
Abstract
Orthostatic hypotension is defined as a blood pressure fall of > 20 mm Hg systolic and/or 10 mm Hg diastolic within 3 minutes of an upright position. The Movement Disorders Society commissioned a task force to assess existing clinical rating scales addressing symptoms of orthostatic hypotension in Parkinson's disease. Seven neurologists and a clinimetrician assessed each scale's previous use and critiqued its clinimetric properties. A scale was "recommended" if it had been applied to populations of patients with Parkinson's disease, with data on its use in studies beyond the group that developed the scale, and was found to be clinimetrically valid. A scale was considered "suggested" if it had been applied to Parkinson's disease, but only 1 of the other criteria was applied. A scale was "listed" if it met only 1 criterion. Symptoms of orthostatic hypotension are generally assessed in scales on wider autonomic or nonmotor symptoms. Some scales designed to detect orthostatic hypotension-related symptoms provide information on their severity: the AUTonomic SCale for Outcomes in PArkinson's Disease and the COMPosite Autonomic Symptom Scale met criteria for recommended with some limitations; the Novel Non-Motor Symptoms Scale and the Orthostatic Grading Scale were classified as suggested. The Self-completed Non-Motor Symptoms Questionnaire for Parkinson's Disease was classified as suggested as a tool for screening orthostatic symptoms. However, these and the listed scales need further validation and application before they can be recommended for clinical use in patients with Parkinson's disease.
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Affiliation(s)
- Anne Pavy-Le Traon
- Reference Centre for MSA, University Hospital, INSERM U1048 Eq8, Toulouse, France.
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Wood LD. Clinical Review and Treatment of Select Adverse Effects of Dopamine Receptor Agonists in Parkinsonʼs Disease. Drugs Aging 2010; 27:295-310. [DOI: 10.2165/11318330-000000000-00000] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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11
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Chen JJ, Trombetta DP, Fernandez HH. Palliative Management of Parkinson Disease: Focus on Nonmotor, Distressing Symptoms. J Pharm Pract 2008. [DOI: 10.1177/0897190008318370] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Parkinson disease is a progressive neurodegenerative disease that commonly affects elderly persons. In the absence of neuroprotective or curative therapies, currently available therapies only provide symptomatic benefit. Progression to advanced Parkinson disease is often accompanied by functional dependence with increased risk of admission to a long-term care facility. The prevalence of Parkinson disease in long-term care facilities, within the United States, has been estimated to be between 5.2% and 10%. Patients with advanced Parkinson disease also experience other distressing motor and nonmotor conditions, such as motor complications, dementia, depression, gastrointestinal distress, orthostatic hypotension, pain, and psychosis, which can be a challenge for clinicians to manage. The presence of distressing symptoms along with the fact that Parkinson disease remains incurable necessitate discussion on a palliative care approach to this disorder. This article discusses the symptomatic management of distressing symptoms encountered in the long-term care resident with Parkinson disease, including motor complications and nonmotor features.
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Affiliation(s)
- Jack J. Chen
- Schools of Medicine and Pharmacy, Movement Disorders Center, Loma Linda University, California,
| | - Dominick P. Trombetta
- Geriatrics/Internal Medicine, College of Pharmacy and Nursing, Wilkes University, Wilkes-Barre, Pennsylvania
| | - Hubert H. Fernandez
- Department of Neurology, McKnight Brain Institute/University of Florida, Gainesville, Florida, Movement Disorders Center
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Jourdan G, Verwaerde P, Pathak A, Tran MA, Montastruc JL, Senard JM. In vivo pharmacodynamic interactions between two drugs used in orthostatic hypotension ? midodrine and dihydroergotamine. Fundam Clin Pharmacol 2007; 21:45-53. [PMID: 17227444 DOI: 10.1111/j.1472-8206.2006.00450.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
A combination of midodrine and dihydroergotamine (DHE) is frequently used clinically in patients suffering from severe orthostatic hypotension (OH). Whereas midodrine acts as a selective, peripheral alpha1-receptor agonist, DHE displays complex pharmacology and can behave as an alpha-adrenergic receptor agonist or antagonist. Surprisingly, the consequences of such a combination on blood pressure have never been investigated. The present study was performed in order to evaluate the pressor effects induced by the administration of both midodrine and DHE in old conscious dogs (n = 6) in experimental condition reproducing autonomic failure-related baroreflex dysfunction (atropine 0.1 mg/kg). For this purpose, we first studied the relative potency and intrinsic activity of each agonist and noradrenaline (NA) for the alpha1-adrenergic receptor. The orders of potency obtained in our study were 0.35, 11 and 400 microg/kg for NA, DHE and midodrine, and intrinsic activity: NA > midodrine > DHE. These results strongly suggest that DHE really acts in vivo as an alpha1-adrenoceptor partial agonist. Afterwards, the pressor effects of coadministration of midodrine (0.4 mg/kg) and DHE (15 microg/kg) were investigated: in one setting, midodrine was first administered, followed by DHE; in another, DHE was first administered, followed by midodrine. Our results show that in conscious dogs, the combination of midodrine and DHE leads to near-complete abolition of the pressor effect induced by the first administered drug. This in vivo proof of such antagonistic effects on blood pressure could explain clinical observations of worsening of OH in humans administered midodrine plus DHE. Although in vivo results obtained in conscious healthy dogs need to be experimentally and clinically confirmed in humans suffering from OH, these results strongly suggest that a midodrine-DHE combined treatment should be avoided in clinical practice.
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Affiliation(s)
- Géraldine Jourdan
- Inserm, U586, Unité de Recherches sur les Obésités, F-31432 Toulouse, France.
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Martignoni E, Tassorelli C, Nappi G. Cardiovascular dysautonomia as a cause of falls in Parkinson's disease. Parkinsonism Relat Disord 2006; 12:195-204. [PMID: 16621660 DOI: 10.1016/j.parkreldis.2006.02.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2005] [Revised: 01/28/2006] [Accepted: 02/01/2006] [Indexed: 11/18/2022]
Abstract
Parkinson's disease (PD) patients have a ninefold increased risk of recurring falls compared to healthy controls. The risk of falling due to cardiovascular dysautonomia (CVD) is not quantifiable. But, CVD is an integral part of the disease and at least 20% of PD patients suffer from orthostatic hypotension, an expression of CVD. One way to reduce falls due to CVD in PD patients could be to give adequate information on the relationship between falling risks and cardiovascular dysautonomia to patients and their caregivers. Moreover, drugs given for PD might contribute to OH and we propose that education and non-pharmacological strategies for its treatment might be preferable, especially because of the low efficacy of drugs available for the treatment of OH and the frailty of elderly PD patients.
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Affiliation(s)
- Emilia Martignoni
- Unit of Neurorehabilitation and Movement Disorders, IRCCS S. Maugeri Foundation, Scientific Institute of Veruno (NO) and Department of Medical Sciences, University of Piemonte Orientale A. Avogadro, Novara, Italy.
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14
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Pathak A, Raoul V, Montastruc JL, Senard JM. Adverse drug reactions related to drugs used in orthostatic hypotension: a prospective and systematic pharmacovigilance study in France. Eur J Clin Pharmacol 2005; 61:471-4. [PMID: 15991040 DOI: 10.1007/s00228-005-0941-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2004] [Accepted: 04/04/2005] [Indexed: 10/25/2022]
Abstract
OBJECTIVE The aim of the present study was to investigate and characterise adverse drug reactions (ADRs) to drugs used in France for orthostatic hypotension (OH). METHODS In this prospective and systematic study, 121 consecutive out-patients suffering from primary (Parkinson's disease, pure autonomic failure, multiple system atrophy, Lewy bodies disease) or secondary (diabetic and non-diabetic peripheral neuropathies) autonomic failure with symptomatic OH requiring pharmacological treatment with at least one drug marketed in France for OH were included together with six patients with refractory neurocardiogenic syncope. RESULTS Of the patients, 85 received a monotherapy-mainly with midodrine (49.4%)-and 42 received various combinations, the association of midodrine and fludrocortisone being the most frequent (66.6%). Of all the 127 patients, 88 suffered from a total of 141 ADRs (1.60 per patient) with no statistical difference in ADR frequency between monotherapy and drug combinations (P>0.05). Among ADRs, 24 (17.0%) were considered as "serious" and 16 (11.3%) were considered as "unexpected", most of them observed with heptaminol. CONCLUSIONS This study shows a high frequency of ADRs (especially serious and unexpected ADRs) with antihypotensive drugs. It strongly suggests the need for a better evaluation of the safety profile of antihypotensive drugs and improvement in summary of product characteristics.
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Affiliation(s)
- Atul Pathak
- Service de Pharmacologie Clinique, Centre Midi-Pyrénées de Pharmacovigilance, de Pharmacoépidémiologie et d'Informations sur le Médicament, Hôpitaux de Toulouse, 37 allées Jules Guesde, 31073, Toulouse cedex 7, France
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