[Late-Onset Dyskinesia Occurring During Antipsychotic Treatment for Schizophrenia: Treatments for Tardive Dyskinesia]

Tardive dyskinesia is recognized as buccolingual dyskinesia, but also includes various involuntary movements, such as chorea, dystonia, myoclonus, and tremor. Tardive dyskinesia can be treated depending on the type of movement disorder present. Antipsychotics causing tardive dyskinesia should be reduced in dosage or should be discontinued. However, the treatment of schizophrenia is important, and neurologists must treat tardive dyskinesia in collaboration with psychiatrists taking care of patients with tardive dystonia. Various treatments, such as VMAT-2 inhibitors or tetrabenazine, reserpine, dopamine receptor antagonists, botulinum toxin therapy, anticholinergic agents, or deep brain stimulation, are trialed, depending on the type of movement disorder and the degree of severity of the disorder.

Characteristics of Inpatients Prescribed Dopamine Receptor Blocking Agents

Dopamine receptor blocking agents (DRBAs, also known as antipsychotics) are frequently used in hospitalized patients. These medications carry a significant side effect burden and should be used judiciously. This purpose of this study is to examine patient, disease, and medication characteristics associated with the use of DRBAs in the inpatient setting to better understand current prescribing patterns and opportunities for optimization. A retrospective analysis was performed of 17,224 patients with at least one inpatient DRBA order placed between 1/1/2018-12/31/2019. The study population at this community hospital network in the United States contained those with (71.0%) and without (29.0%) psychiatric diagnoses, and the mean number of DRBA medications for each patient was 2.4 +/- 1.1. The characteristics of single, male, government-sponsored health insurance, movement disorder, DRBA adverse effects, and medication non-adherence were associated with significantly greater mean total DRBA medications prescribed. Medication non-adherence and prescription of a long-acting injectable (LAI) DRBA were greater in single and male patients, while suicidality was more likely in those with a movement disorder or DRBA adverse effect. Specific agents were also significantly associated with cardiovascular disease and metabolic disorder diagnoses. Based on the findings of this study, several patient, disease, and medication factors are related to the use of DRBAs in the hospital setting. It is important to further explore these associations in order to determine the appropriateness of DRBA prescribing and identify areas for improvement.

[Tardive akathisia after long-term metoclopramide treatment]

This case report describes a 57-year-old male with symptoms of tardive akathisia after long-term metoclopramide treatment. As metoclopramide is a dopamine receptor antagonist, it has the potential to cause drug-induced movement disorders, including akathisia, which is characterised by an inner restlessness resulting in a need for constant movement. Tardive akathisia, in contrast to acute akathisia, evolves after prolonged exposure to the triggering medication and can be a permanent condition. Treatment duration of metoclopramide should be restricted, and awareness of neurological side effects is important.

Cariprazine as a Treatment Option for Depressive Episodes Associated with Bipolar 1 Disorder in Adults: An Evidence-Based Review of Recent Data

Depressive episodes, the most frequent episodes in bipolar disorder, contribute in large part to poor functional outcomes. Very few treatments, however, have been approved by the Food and Drug Administration for the treatment of bipolar depression. Cariprazine, a broad-spectrum dopamine antagonist/partial agonist with dopamine D3/D2 (preferring D3) and serotonin 5-HT1A receptor partial agonist properties, was recently approved. A review of the literature suggests that it is an effective and well-tolerated treatment for bipolar depression.

Management of Tardive Syndrome: Medications and Surgical Treatments

Tardive syndrome (TS) is an iatrogenic, often persistent movement disorder caused by drugs that block dopamine receptors. It has a broad phenotype including movement (orobuccolingual stereotypy, dystonia, tics, and others) and nonmotor features (akathisia and pain). TS has garnered increased attention of late because of the Food and Drug Administration approval of the first therapeutic agents developed specifically for this purpose. This paper will begin with a discussion on pathogenesis, clinical features, and epidemiology. However, the main focus will be treatment options currently available for TS including a suggested algorithm based on current evidence. Recently, there have been significant advances in TS therapy, particularly with the development of 2 new vesicular monoamine transporter type 2 inhibitors for TS and with new data on the efficacy of deep brain stimulation. The discussion will start with switching antipsychotics and the use of clozapine monotherapy which, despite the lack of higher-level evidence, should be considered for the treatment of psychosis and TS. Anti-dyskinetic drugs are separated into 3 tiers: 1) vesicular monoamine transporter type 2 inhibitors, which have level A evidence, are approved for use in TS and are recommended first-choice agents; 2) drugs with lower level of evidence for efficacy including clonazepam, Ginkgo biloba, and amantadine; and 3) drugs that have the potential to be beneficial, but currently have insufficient evidence including levetiracetam, piracetam, vitamin B6, melatonin, baclofen, propranolol, zolpidem, and zonisamide. Finally, the roles of botulinum toxin and surgical therapy will be examined. Current therapies, though improved, are symptomatic. Next steps should focus on the prevention and reversal of the pathogenic process.

Maintenance treatment with antipsychotic drugs for schizophrenia

BACKGROUND

The symptoms and signs of schizophrenia have been linked to high levels of dopamine in specific areas of the brain (limbic system). Antipsychotic drugs block the transmission of dopamine in the brain and reduce the acute symptoms of the disorder. An original version of the current review, published in 2012, examined whether antipsychotic drugs are also effective for relapse prevention. This is the updated version of the aforesaid review.

OBJECTIVES

To review the effects of maintaining antipsychotic drugs for people with schizophrenia compared to withdrawing these agents.

SEARCH METHODS

We searched the Cochrane Schizophrenia Group's Study-Based Register of Trials including the registries of clinical trials (12 November 2008, 10 October 2017, 3 July 2018, 11 September 2019).

SELECTION CRITERIA

We included all randomised trials comparing maintenance treatment with antipsychotic drugs and placebo for people with schizophrenia or schizophrenia-like psychoses.

DATA COLLECTION AND ANALYSIS

We extracted data independently. For dichotomous data we calculated risk ratios (RR) and their 95% confidence intervals (CIs) on an intention-to-treat basis based on a random-effects model. For continuous data, we calculated mean differences (MD) or standardised mean differences (SMD), again based on a random-effects model.

MAIN RESULTS

The review currently includes 75 randomised controlled trials (RCTs) involving 9145 participants comparing antipsychotic medication with placebo. The trials were published from 1959 to 2017 and their size ranged between 14 and 420 participants. In many studies the methods of randomisation, allocation and blinding were poorly reported. However, restricting the analysis to studies at low risk of bias gave similar results. Although this and other potential sources of bias limited the overall quality, the efficacy of antipsychotic drugs for maintenance treatment in schizophrenia was clear. Antipsychotic drugs were more effective than placebo in preventing relapse at seven to 12 months (primary outcome; drug 24% versus placebo 61%, 30 RCTs, n = 4249, RR 0.38, 95% CI 0.32 to 0.45, number needed to treat for an additional beneficial outcome (NNTB) 3, 95% CI 2 to 3; high-certainty evidence). Hospitalisation was also reduced, however, the baseline risk was lower (drug 7% versus placebo 18%, 21 RCTs, n = 3558, RR 0.43, 95% CI 0.32 to 0.57, NNTB 8, 95% CI 6 to 14; high-certainty evidence). More participants in the placebo group than in the antipsychotic drug group left the studies early due to any reason (at seven to 12 months: drug 36% versus placebo 62%, 24 RCTs, n = 3951, RR 0.56, 95% CI 0.48 to 0.65, NNTB 4, 95% CI 3 to 5; high-certainty evidence) and due to inefficacy of treatment (at seven to 12 months: drug 18% versus placebo 46%, 24 RCTs, n = 3951, RR 0.37, 95% CI 0.31 to 0.44, NNTB 3, 95% CI 3 to 4). Quality of life might be better in drug-treated participants (7 RCTs, n = 1573 SMD -0.32, 95% CI to -0.57 to -0.07; low-certainty evidence); probably the same for social functioning (15 RCTs, n = 3588, SMD -0.43, 95% CI -0.53 to -0.34; moderate-certainty evidence). Underpowered data revealed no evidence of a difference between groups for the outcome 'Death due to suicide' (drug 0.04% versus placebo 0.1%, 19 RCTs, n = 4634, RR 0.60, 95% CI 0.12 to 2.97,low-certainty evidence) and for the number of participants in employment (at 9 to 15 months, drug 39% versus placebo 34%, 3 RCTs, n = 593, RR 1.08, 95% CI 0.82 to 1.41, low certainty evidence). Antipsychotic drugs (as a group and irrespective of duration) were associated with more participants experiencing movement disorders (e.g. at least one movement disorder: drug 14% versus placebo 8%, 29 RCTs, n = 5276, RR 1.52, 95% CI 1.25 to 1.85, number needed to treat for an additional harmful outcome (NNTH) 20, 95% CI 14 to 50), sedation (drug 8% versus placebo 5%, 18 RCTs, n = 4078, RR 1.52, 95% CI 1.24 to 1.86, NNTH 50, 95% CI not significant), and weight gain (drug 9% versus placebo 6%, 19 RCTs, n = 4767, RR 1.69, 95% CI 1.21 to 2.35, NNTH 25, 95% CI 20 to 50).

AUTHORS' CONCLUSIONS

For people with schizophrenia, the evidence suggests that maintenance on antipsychotic drugs prevents relapse to a much greater extent than placebo for approximately up to two years of follow-up. This effect must be weighed against the adverse effects of antipsychotic drugs. Future studies should better clarify the long-term morbidity and mortality associated with these drugs.

Cardiovascular alterations in rats with Parkinsonism induced by 6-OHDA and treated with Domperidone

After Alzheimer, Parkinson disease (PD) is the most frequently occurring progressive, degenerative neurological disease. It affects both sympathetic and parasympathetic nervous systems in a variable fashion. Cardiovascular symptoms are present in almost all stages of PD and narrower heart rate variability is the earliest sign. Administration of Levodopa to PD patients has proven to provide some degree of neurological protection. This drug, however, causes side effects including nausea and vomiting, lessened by the administration of domperidone. Autopsies in PD patients led some researchers to suggest the involvement of the ventricular arrhythmia induced by domperidone. The aim of the present study was to determine the impact of the adjusted human maximal dose of domperidone, on cardiological features of Wistar rats. domperidone was administered to both 6-hydroxydopamine Parkinsonism models and regular Wistar rats. Quantitative analysis of ranges of heart beat variation showed significant abnormal distribution in both groups receiving domperidone as compared with respective sham counterparts. However, qualitative analysis of Poincaré plots showed that 6-hydroxydopamine Parkinsonism models receiving domperidone had the narrowest full range of heart beat and the worst distribution heart beat ranges as compared with all study groups corroborating with previous suggestion that domperidone administration to PD patients is likely to play a role in sudden unexpected death in this group of patients.

Randomized, Double-Blind, Placebo-Controlled Study of Intravenous Amisulpride as Treatment of Established Postoperative Nausea and Vomiting in Patients Who Have Had No Prior Prophylaxis

BACKGROUND

Postoperative nausea and vomiting (PONV) occurs commonly in surgical patients despite widespread prophylactic antiemetic use. Rescue options are currently limited. 5HT3 antagonists are most frequently used for prophylaxis, but if they fail, additional doses are not effective as rescue medication. Intravenous (IV) amisulpride, a well-studied D2/D3 antagonist, has been shown in trials to prevent PONV. This study was designed to determine if amisulpride could be used to treat established PONV in patients at low-to-moderate risk of PONV who had not received any prior prophylaxis.

METHODS

Men and women aged over 18 years were permitted to enroll if they were to undergo general inhalational anesthesia, expected to last at least 1 hour, for an outpatient or inpatient surgical procedure. Patients who then suffered PONV were randomized equally to 1 of 3 single-dose IV regimens: placebo or 5 or 10 mg amisulpride. The primary end point was complete response, defined as no emesis in the period 30 minutes to 24 hours after study drug treatment and no use of rescue medication in the entire 24-hour period.

RESULTS

One thousand nine hundred eighty-eight patients were enrolled preoperatively, of whom 560 were randomized to a treatment arm. Complete response occurred in 39 of 181 patients (21.5%) in the placebo group compared to 60 of 191 patients (31.4%; P = .016) and 59 of 188 patients (31.4%; P = .016) in the amisulpride 5 and 10 mg groups, respectively. The adverse event profile of amisulpride at either dose was similar to placebo.

CONCLUSIONS

IV amisulpride at 5 and 10 mg was safe and efficacious in the treatment of established PONV in surgical patients undergoing general anesthesia with no prior PONV prophylaxis.

Effects of chronic aspartame consumption on MPTP-induced Parkinsonism in male and female mice

BACKGROUND

Parkinson's disease is a progressive neurodegenerative disorder. Aspartame (l-aspartyl-l-phenylalanine methyl ester), a low calorie sweetener used in foods and beverages.

OBJECTIVES

This study investigated the effect of chronic aspartame intake on Parkinsonism induced by 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP).

METHOD

Forty-eight mice (24 males and 24 females): control, aspartame, MPTP, and aspartame + MPTP groups tested by Y-maze, stepping, forced swimming and olfactory preference tests. Brain tissues examined for dopamine content, tyrosine hydroxylase, inducible nitric oxide synthase (iNOS), glutathione peroxidase, phosphorylated tau and α-synuclein protein. Histopathological evaluation of brain sections at the level of basal ganglia was done.

RESULTS

Decreased dopamine content, tyrosine hydroxylase expression, glutathione peroxidase expression and increased iNOS, tau and α-synuclein expression in groups received aspartame, MPTP or both agents simultaneously in both males and females group.

CONCLUSIONS

Increased dopaminergic degeneration and complications with chronic aspartame consumption and more injury in male groups.

Probiotics Affect One-Carbon Metabolites and Catecholamines in a Genetic Rat Model of Depression

SCOPE

Probiotics may influence one-carbon (C1) metabolism, neurotransmitters, liver function markers, or behavior.

METHODS AND RESULTS

Male adult Flinders Sensitive Line rats (model of depression, FSL; n = 22) received Lactobacillus helveticus R0052 and Bifidobacterium longum R0175 (109 or 1010 colony-forming units per day) or vehicle for 10 weeks. The controls, Flinders Resistant Line rats (FRL, n = 8), only received vehicle. C1-related metabolites were measured in plasma, urine, and different tissues. Monoamine concentrations were measured in plasma, hippocampus, and prefrontal cortex. Vehicle-treated FSL rats had higher plasma concentrations of betaine, choline, and dimethylglycine, but lower plasma homocysteine and liver S-adenosylmethionine (SAM) than FRLs. FSL rats receiving high-dose probiotics had lower plasma betaine and higher liver SAM compared to vehicle-treated FSL rats. FSLs had higher concentrations of norepinephrine, dopamine, and serotonin than FRLs across various brain regions. Probiotics decreased plasma dopamine in FSLs in a dose-dependent manner. There were no detectable changes in liver function markers or behavior.

CONCLUSIONS

Probiotics reduced the flow of methyl groups via betaine, increased liver SAM, and decreased plasma dopamine and norepinephrine. Since these changes in methylation and catecholamine pathways are known to be involved in several diseases, future investigation of the effect of probiotics is warranted.

A double-blind, placebo-controlled, crossover trial of the selective dopamine D1 receptor antagonist ecopipam in patients with Lesch-Nyhan disease

Lesch-Nyhan disease (LND) is a genetic disorder that has characteristic metabolic, neurologic, and behavioral features. There are multiple behavioral problems including impulsivity, aggressiveness, and severe recurrent self-injurious behavior (SIB). This last behavior varies considerably across subjects and may encompass self-biting, self-hitting, scratching, head banging, and other injurious actions. Current treatments for SIB involve behavioral extinction, sedatives, physical restraints, and removal of teeth. Because these interventions do not reliably control SIB, better treatments are urgently needed. Animal studies have suggested that D1-dopamine receptor antagonists such as ecopipam may suppress SIB. These observations have led to proposals that such drugs might provide effective treatment for in LND. The current study describes the results of a double-blind, three-period, crossover trial of a single dose of ecopipam in subjects with LND. The study was designed for 20 patients, but it was terminated after recruitment of only 10 patients, because interim analysis revealed unanticipated side effects. These side effects were most likely related to starting with a single large dose without any titration phase. Despite the limited data due to early termination, the drug appeared to reduce SIB in most cases. Subjects who completed the trial were eligible to continue the drug in an open-label extension phase lasting a year, and one patient who elected to continue has maintained a striking reduction in SIB for more than a year with no apparent side effects. These results suggest ecopipam could be a useful treatment for SIB in, but further studies are needed to establish an appropriate dosing regimen.

Towards rational drug treatment of Lesch-Nyhan disease

Lesch-Nyhan disease (LND) is a rare X-chromosomal purine metabolism disorder. LND is characterized by self-injurious behavior (SIB) for which there is no drug treatment. This commentary places a recent clinical study by Khasnavis et al. (Mol. Genetic. Metab., in press) on drug treatment of SIB into a broader context. Although the study by Khasnavis et al. was no break-through in terms of "positive" results, nonetheless, it presents an excellent model of how clinical studies in general and clinical studies on rare diseases should be conducted.

A clinical trial of safety and tolerability for the selective dopamine D1 receptor antagonist ecopipam in patients with Lesch-Nyhan disease

Lesch-Nyhan disease (LND) is an inherited metabolic disorder characterized by the overproduction of uric acid and distinct behavioral, cognitive, and motor abnormalities. The most challenging clinical problem is self-injurious behavior (SIB), which includes self-biting, self-hitting, self-abrasion, and other features. Currently, these behaviors are managed by behavioral extinction, sedatives, physical restraints, and removal of teeth. More effective treatments are needed. Pre-clinical studies have led to the hypothesis that D1-dopamine receptor antagonists may provide useful treatments for SIB in LND. Ecopipam is one such selective D1-dopamine receptor antagonist. This report summarizes results of a dose-escalation study of the safety and tolerability of ecopipam in 5 subjects with LND. The results suggest that ecopipam is well tolerated, with sedation being the most common dose-limiting event. Several exploratory measures also suggest ecopipam might reduce SIB in this population. These results support the hypothesis that D1-dopamine receptor antagonists may be useful for suppressing SIB in LND, and encourage further studies of efficacy.

Frontal D2/3 Receptor Availability in Schizophrenia Patients Before and After Their First Antipsychotic Treatment: Relation to Cognitive Functions and Psychopathology

BACKGROUND

We have previously reported associations between frontal D2/3 receptor binding potential positive symptoms and cognitive deficits in antipsychotic-naïve schizophrenia patients. Here, we examined the effect of dopamine D2/3 receptor blockade on cognition. Additionally, we explored the relation between frontal D2/3 receptor availability and treatment effect on positive symptoms.

METHODS

Twenty-five antipsychotic-naïve first-episode schizophrenia patients were examined with the Positive and Negative Syndrome Scale, tested with the cognitive test battery Cambridge Neuropsychological Test Automated Battery, scanned with single-photon emission computerized tomography using the dopamine D2/3 receptor ligand [(123)I]epidepride, and scanned with MRI. After 3 months of treatment with either risperidone (n=13) or zuclopenthixol (n=9), 22 patients were reexamined.

RESULTS

Blockade of extrastriatal dopamine D2/3 receptors was correlated with decreased attentional focus (r = -0.615, P=.003) and planning time (r = -0.436, P=.048). Moreover, baseline frontal dopamine D2/3 binding potential and positive symptom reduction correlated positively (D2/3 receptor binding potential left frontal cortex rho = 0.56, P=.003; D2/3 receptor binding potential right frontal cortex rho = 0.48, P=.016).

CONCLUSIONS

Our data support the hypothesis of a negative influence of D2/3 receptor blockade on specific cognitive functions in schizophrenia. This is highly clinically relevant given the well-established association between severity of cognitive disturbances and a poor functional outcome in schizophrenia. Additionally, the findings support associations between frontal D2/3 receptor binding potential at baseline and the effect of antipsychotic treatment on positive symptoms.

Transient psychosis in women on clomiphene, bromocriptine, domperidone and related endocrine drugs

BACKGROUND

There have been reports of transient psychosis in women medicated for gynecologic conditions.

OBJECTIVE

The aim of this paper was to explore this literature.

METHOD

The PubMed and Google Scholar databases were searched for relevant case reports Results: The following reports were found: psychosis induced by gonadotropin-releasing hormone in the treatment of endometriosis, by clomiphene treatment for infertility, by bromocriptine treatment for milk suppression and by the withdrawal of domperidone prescribed as a galactologue as well as by the withdrawal of estrogen replacement therapy.

CONCLUSION

In susceptible women, psychotic symptoms can result from treatments that reduce estrogen levels, such as leuprolide acetate or clomiphene, or treatments that increase dopamine levels (bromocriptine). Psychosis can also be caused indirectly when estrogen treatment is discontinued or dopamine antagonism (e.g. domperidone) withdrawn. Estrogen-reducing and dopamine-increasing treatments used in gynecology need to be carefully monitored.

[NON-RESPIRATORY FUNCTION OF THE LUNGS IN THE NIGROSTRIATAL DOPAMINERGIC SYSTEM DYSFUNCTION]

The study presents a comprehensive of the metabolism and the fractional composition of li- pids surfactant, water balance, hemostatic activity of the lungs in neyrodegeneration substantia nigra of the brain induced by stereotaxic microinjection of 6--hydroxydopamine and systemic administration of haloperidol. It is shown that a breach of dopaminergic neurotransmission leads to deterioration of surface-active properties of the alveolar lining of the complex against a decrea- se of phospholipids, cholesterol, phosphatidylcholine and lysophospholipids enhance the pulmo- nary surfactant in the activation of phospholipase hydrolysis and lipid peroxidation. Intranigral introduction neurotoxin accompanied by increased blood supply to the lungs and the blood coagu- lation potential of the pulmonary circulation, the blockade D2-receptors--hyporhydration lung tissue. The results obtained indicate the formation of dysregulation pneumopathy dysfunction nigrostriatal dopaminergic system.

Missing dosages and neuroleptic usage may prolong length of stay in hospitalized Parkinson's disease patients

Background

Parkinson’s disease patients are more likely to be hospitalized, have higher rates of hospital complications, and have an increased risk of deterioration during hospitalization. Length of stay is an important underlying factor for these increased risks. We aimed to investigate potential medication errors that may occur during hospitalization and its impact on length of hospital stay.

Methods

A cross-sectional chart review of 339 consecutive hospital encounters from 212 PD subjects was performed. Medication errors were defined as wrong timing or omission of administration for dopaminergic drugs and administration of contraindicated dopamine blockers. An analysis of covariance was applied to examine whether these medication errors were related to increased length of hospital stays.

Results

A significant effect for dopaminergic administration (p<0.01) on length of hospital stay was observed. Subjects who had delayed administration or missed at least one dose stayed longer (M=8.2 days, SD=8.9 vs. M=3.6 days SD=3.4). Contraindicated dopamine blocking agents were administered in 23% (71/339) of cases, and this was also significantly related to an increased length of stay (M=8.2 days, SD=8.9 vs. M=3.6 days SD=3.4), p<0.05. Participants who received a contraindicated dopamine blocker stayed in the hospital longer (M=7.5 days, SD=9.1) compared to those who did not (M=5.9 days, SD=6.8). Neurologists were consulted in 24.5% of encounters. Specialty consultation had no effect on the medication related errors.

Conclusions

Missing dopaminergic dosages and administration of dopamine blockers occur frequently in hospitalized Parkinson’s disease patients and this may impact length of stay. These potentially modifiable factors may reduce the risk of a longer stay related to hospitalization.

The dual role of domperidone in gastroparesis and lactation

Domperidone is a prokinetic agent used as a second-line treatment option for gastroparesis in those unable to tolerate metoclopramide. Via inhibition of dopamine-2 receptors within the gastrointestinal tract and various parts of the central and peripheral nervous system, domperidone helps to facilitate peristalsis and gastric emptying. A major side effect of domperidone is prolactinemia, allowing it to be used off-label for the purpose of inducing lactation. In the U.S., domperidone is currently not U.S. Food and Drug Administration approved due to various case reports and literature associating the risks of sudden cardiac death and ventricular arrhythmia with the use of domperidone. Despite the evidence against the use of domperidone, it is still being widely used in Canada and Europe for both gastroparesis and to induce milk let-down. This article is a literature review intending to assess the risks associated with the use of domperidone in gastroparesis and lactation.

[Pharmaceutical treatment of lactation deficiency lacks evidence]

In this review we have looked at the evidence for the pharmacological treatment of lactation deficiency. Five RCTs (n = 166) of metoclopramide found no effect on lactation and two RCTs (n = 26) of older date and lesser quality found significant effect. One RCT (n = 51) of syntocinon found no effect on lactation and two older RCTs (n = 60) of lesser quality found significant effect. Three RCTs (n = 105) found significant effect of domperidone on lactation. Education on breastfeeding is important to avoid the need for pharmacological treatment.

Neuroleptic malignant syndrome induced by combination therapy with tetrabenazine and tiapride in a Japanese patient with Huntington's disease at the terminal stage of recurrent breast cancer

We herein describe the case of an 81-year-old Japanese woman with neuroleptic malignant syndrome that occurred 36 days after the initiation of combination therapy with tiapride (75 mg/day) and tetrabenazine (12.5 mg/day) for Huntington's disease. The patient had been treated with tiapride or tetrabenazine alone without any adverse effects before the administration of the combination therapy. She also had advanced breast cancer when the combination therapy was initiated. To the best of our knowledge, the occurrence of neuroleptic malignant syndrome due to combination therapy with tetrabenazine and tiapride has not been previously reported. Tetrabenazine should be administered very carefully in combination with other neuroleptic drugs, particularly in patients with a worsening general condition.

[Use of itopride in the symptoms of functional dyspepsia in Russia: results of a phase IV prospective open-label multicenter clinical trial]

AIM

To evaluate the efficacy and safety of itopride used to treat the symptoms of functional dyspepsia (FD) of the upper gastrointestinal tract.

SUBJECTS AND METHODS

A prospective, open-label, multicenter trial using as a control the placebo response obtained in the previous investigations enrolled 96 adult patients. The diagnosis of FD corresponded to its Rome II criteria. Patients received itopride (Ganaton) oral tablets (50 mg) 3 times daily for 8 weeks. When included into the trial, the patients were orally given itopride (ganaton) tablets (50 mg) thrice daily before meals for 8 weeks. The patients' status was evaluated during (at weeks 4 and 8) and after (at week 12) treatment. Treatment response was assessed using the Global Patient Assessment (GPA) and the Leeds Dyspepsia Questionnaire (LDQ). To evaluate the safety of itopride use, the investigators studied the frequency of adverse events and carried out laboratory tests (renal and liver function tests) and electrocardiography (ECG).

RESULTS

The GPA showed that 53.76, 85.71, and 82.22% of the patients achieved a therapeutic effect of itopride at weeks 4, 8, and 12, respectively. The proportion of the patients who achieved the therapeutic effect (86%) at week 8 was higher than the historical placebo controls in the previous studies--45% (86% vs 45%; X2 = 68.868, df = 3; p < 0.001). The mean LDQ score at week 8 was significantly lower than that at baseline (2.09 and 9.36 scores; p < 0.001); 6 nonserious adverse events occurred in 3 (3.12%) of the 96 patients. During the follow-up period, there was a mild adverse event that was related to the test drug (atrial extrasystole as evidenced by ECG) and resolved a few days later.

CONCLUSION

Itopride is an effective and well-tolerated drug in the treatment of functional dyspepsia in the Russian patients.

Genetics of adverse reactions to haloperidol in a mouse diallel: a drug-placebo experiment and Bayesian causal analysis

Haloperidol is an efficacious antipsychotic drug that has serious, unpredictable motor side effects that limit its utility and cause noncompliance in many patients. Using a drug-placebo diallel of the eight founder strains of the Collaborative Cross and their F1 hybrids, we characterized aggregate effects of genetics, sex, parent of origin, and their combinations on haloperidol response. Treating matched pairs of both sexes with drug or placebo, we measured changes in the following: open field activity, inclined screen rigidity, orofacial movements, prepulse inhibition of the acoustic startle response, plasma and brain drug level measurements, and body weight. To understand the genetic architecture of haloperidol response we introduce new statistical methodology linking heritable variation with causal effect of drug treatment. Our new estimators, "difference of models" and "multiple-impute matched pairs", are motivated by the Neyman-Rubin potential outcomes framework and extend our existing Bayesian hierarchical model for the diallel (Lenarcic et al. 2012). Drug-induced rigidity after chronic treatment was affected by mainly additive genetics and parent-of-origin effects (accounting for 28% and 14.8% of the variance), with NZO/HILtJ and 129S1/SvlmJ contributions tending to increase this side effect. Locomotor activity after acute treatment, by contrast, was more affected by strain-specific inbreeding (12.8%). In addition to drug response phenotypes, we examined diallel effects on behavior before treatment and found not only effects of additive genetics (10.2-53.2%) but also strong effects of epistasis (10.64-25.2%). In particular: prepulse inhibition showed additivity and epistasis in about equal proportions (26.1% and 23.7%); there was evidence of nonreciprocal epistasis in pretreatment activity and rigidity; and we estimated a range of effects on body weight that replicate those found in our previous work. Our results provide the first quantitative description of the genetic architecture of haloperidol response in mice and indicate that additive, dominance-like inbreeding and parent-of-origin effects contribute strongly to treatment effect heterogeneity for this drug.

[Treatment of tardive syndromes]

Tardive syndromes associated with dopamine-receptor blocking agents have heterogeneous appearance. The treatment of tardive dyskinesia, dystonia, myoclonus, tourettism, tremor and akathisia is challenging for both psychiatrists and neurologists. Lack of randomized and controlled examinations for many routinely applied clinical therapeutic options make the development of clinical guidelines difficult. The present review article summarizes the available evidence for the treatment of tardive syndromes. According to the treatment guideline published by the American Academy of Neurology in 2013, the usage of clonazepam, ginkgo biloba, amantadine and tetrabenazine has enough evidence to draw conclusions. Although lowering or stopping the eliciting agent, changing to atypical antipsychotics, and adding anticholinergics are widely used techniques, there are no convincing controlled studies available to support their efficacy. The usage of Vitamin E, levetiracetam, propranolol, botulinum toxin and deep brain stimulation may be promising treatment options in the future.

Pharmacological evaluation of SN79, a sigma (σ) receptor ligand, against methamphetamine-induced neurotoxicity in vivo

Methamphetamine is a highly addictive psychostimulant drug of abuse, causing hyperthermia and neurotoxicity at high doses. Currently, there is no clinically proven pharmacotherapy to treat these effects of methamphetamine, necessitating identification of potential novel therapeutic targets. Earlier studies showed that methamphetamine binds to sigma (σ) receptors in the brain at physiologically relevant concentrations, where it "acts in part as an agonist." SN79 (6-acetyl-3-(4-(4-(4-florophenyl)piperazin-1-yl)butyl)benzo[d]oxazol-2(3H)-one) was synthesized as a putative σ receptor antagonist with nanomolar affinity and selectivity for σ receptors over 57 other binding sites. SN79 pretreatment afforded protection against methamphetamine-induced hyperthermia and striatal dopaminergic and serotonergic neurotoxicity in male, Swiss Webster mice (measured as depletions in striatal dopamine and serotonin levels, and reductions in striatal dopamine and serotonin transporter expression levels). In contrast, di-o-tolylguanidine (DTG), a well established σ receptor agonist, increased the lethal effects of methamphetamine, although it did not further exacerbate methamphetamine-induced hyperthermia. Together, the data implicate σ receptors in the direct modulation of some effects of methamphetamine such as lethality, while having a modulatory role which can mitigate other methamphetamine-induced effects such as hyperthermia and neurotoxicity.

[Medication-related oculogyric crises: a description of four cases and a review of the literature]

INTRODUCTION

Oculogyric crises are considered to be a form of focal dystonia and can be observed as reactions to pharmaceuticals. The signs and symptoms may be confused with epileptic crises.

AIMS

To describe the clinical features and progress of patients with pharmaceutical-related oculogyric crises and to carry out a review of the topic.

CASE REPORTS

We conducted a retrospective, descriptive study of four patients evaluated in the neurology service due to oculogyric crises. The patients had been diagnosed with an associated conduct disorder requiring treatment with antipsychotic drugs. The episodes of oculogyric crises did not correlate with the findings in the electroencephalogram. They responded well to the reduction in dosage or to withdrawal of the apparent causing agent.

CONCLUSIONS

The clinical picture does not present only in patients treated with antipsychotics but is also linked with other pharmaceuticals that are frequently used in daily paediatric practice. When oculogyric crises are the reason for visiting, differential diagnoses must be taken into account in order to avoid unnecessary studies and to carry out an appropriate therapeutic management.

Bilateral dislocation of temporomandibular joint induced by haloperidol following suicide attempt: a case report

Drug induced dystonic reactions are among common presentations of patients in emergency departments, and typically occur with antidopaminergic agents as their extra-pyramidal side effects. Dystonic reactions usually occur within the first few hours or days after commencing a drug or dose increase. Unlike other extra-pyramidal side effects, a patient may experience acute dystonic reactions (ADRs) with the administration of just a single dose. Oromandibular dystonia is a subtype of dystonia which can present with perioral manifestations. In extreme cases, it can lead to temporomandibular dislocation. Haloperidol, as a high potent typical antipsychotic drug, can induce dystonia with blocking D2 dopamine receptors. The present paper reports a case of bilateral dislocation of temporomandibular joint following ingestion of haloperidol in a suicidal attempt in a 17 years old girl.

Effects of domperidone on augmentation of lactation following cesarean delivery at full term

OBJECTIVE

To evaluate the effects of domperidone on breast milk production in women who underwent cesarean at full term.

METHODS

Women who underwent uncomplicated full-term cesarean were randomly assigned to receive domperidone or placebo for 4 consecutive days post partum. Breast milk was collected twice daily via electric breast pump. Baseline milk production was determined by measuring the volume of milk collected on the 1st postpartum day, before initiation of study medication (day 0). The daily volume of milk collected was compared between groups. Adverse treatment-related effects were recorded.

RESULTS

The study was completed by 22 women in the domperidone group and 23 in the placebo group. Compared with day 0, mean increases in milk volume per participant collected on days 1, 2, 3, and 4 were significantly higher in the domperidone (13.6 ± 23.2 mL, 68.5 ± 71.9 mL, 144.5 ± 122.3 mL, and 191.3 ± 136.1 mL) than in the placebo (2.5 ± 4.6 mL, 24.5 ± 26.5 mL, 72.1 ± 55.6 mL, and 91.4 ± 60.3 mL) group. Minor adverse effects were reported by 7 women in the domperidone group.

CONCLUSION

Postpartum treatment with domperidone can augment breast milk production after full-term cesarean, with minimal adverse effects.

[Restless legs syndrome and depression]

Epidemiological studies report an odds ratio of 2-4 for major depression among patients with restless legs syndrome (RLS) compared with healthy controls. Also a high prevalence of RLS in populations of depressed patients is seen. Several possible explanations are proposed, such as dopamine dysfunction, sleep disturbances, shared diagnostic criteria and adverse effects of antidepressive treatment. There is a low degree of evidence for a treatment strategy when depression and RLS coexist. Furthermore, it is important to realize, that some antidepressants can induce or worsen RLS.

[Effects of a neuroleptic analgesia with acepromazine on the blood perfusion of the canine kidney. Examination using the sonographic recordable blood circulation parameters of resistance index and pulsatility index]

OBJECTIVE

Kidney failure after anaesthesia constitutes a serious clinical complication. A number of patients suffer from compensated kidney insufficiency, which may be transformed into an acute kidney insufficiency through additional stress, such as an operation and anaesthesia. The aim of the present study was to investigate the effects of a neurolept analgesia with acepromazine on sonographically accessible blood perfusion parameters.

MATERIAL AND METHODS

Following anaesthesia with acepromazine/l-methadone (0.1 mg/kg BW acepromazine, 0.5 mg/kg BW l-methadone) a sonographic examination of the left kidney was performed in 19 clinically healthy foxhound and beagle dogs. Every 5 minutes resistance index and pulsatility index as well as invasive blood pressure were measured and digitally recorded.

RESULTS

Within 5 minutes after induction of anaesthesia a transient increase of the mean arterial blood pressure occurred. After 10 minutes the blood pressure decreased to the initial value and remained essentially constant to the end of the investigation. Resistance index and pulsatility index showed a similar behaviour: After a small initial decrease during the first 5 minutes both parameters displayed a significant increase. This rise was very pronounced up to approximately 15 minutes and then flattened significantly until the end of the test period after 30 minutes. The values corresponded to those found in vessel stenosis.

CONCLUSION AND CLINICAL RELEVANCE

Due to the described changes this type of anaesthesia should not be used in dogs with nephropathy, even though the results of this experimental study might not be necessarily transferable to the clinical patient.

Benefits of switching women schizophrenic patients to aripiprazole: a case study and brief review of the literature

Hyperprolactinemia, an adverse side-effect of the use of typical and some atypical antipsychotics, has both acute and chronic clinical consequences. When observed in schizophrenic patients, it may be treated by switching the patient to an antipsychotic agent with a lower liability for the induction of hyperprolactinemia. The effects of substituting aripiprazole for other antipsychotic agents on schizophrenic patients with antipsychotic-induced hyperprolactinemia have been previously reported in several studies. Many studies have also noted that aripiprazole can sometimes lead to increases in psychotic symptoms, especially in the period immediately following the switch or when aripiprazole is combined with a dopamine antagonist. Here, we report observations on five female patients who were experiencing symptomatic hyperprolactinemia and psychotic exacerbation while on antipsychotic treatment, yet improved in both conditions after being switched to aripiprazole monotherapy. We also provide a brief review of the existing studies that report the results of switching patients from other antipsychotics to aripiprazole.

Management of psychosis associated with a prolactinoma: case report and review of the literature

BACKGROUND

Prolactinomas are the most common pituitary tumors; they are treated with dopamine agonists, which may cause psychotic symptoms as a side effect. Psychosis is treated with dopamine-receptor blockers that may result in elevated serum prolactin and symptomatic hyperprolactinemia.

OBJECTIVE

The authors will review a case of a patient with a prolactinoma as well as schizophrenia and illustrate the management of psychosis in this case.

METHOD

The review describes the management of prolactinoma, symptoms of hyperprolactinemia, and long-term effects of hyperprolactinemia.

RESULTS

In the case presentation reviewed, the patient was finally discharged on risperidone long-acting injection and testosterone supplementation, with no growth of the adenoma after 3 years.

DISCUSSION

This review provides recommendations and treatment strategy for management of prolactinoma in a patient with schizophrenia.

Use of antiemetics in the management of chemotherapy-related nausea and vomiting in current UK practice

PURPOSE

The main aim of the present study was to assess antiemetic prescriptions used during chemotherapy and identify if these are in agreement with internationally agreed consensus guidelines (MASCC/ASCO).

METHODS

A web-based survey in the UK was carried out collecting data through a 32-item questionnaire using a snowball sampling technique and the email lists of two large oncology societies in the country.

RESULTS

The participants were 154 oncologists and oncology nurse prescribers. Data showed a great variability in antiemetic prescriptions used, most not been in accordance with MASCC/ASCO consensus guidelines. The variability was also reflected in the doses of antiemetics used. Overall, clinicians undertreated patients receiving highly emetogenic chemotherapy and overtreated patients receiving low and minimally emetogenic chemotherapy. Eight of ten clinicians, however, prescribed antiemetics in accordance with consensus guidelines in moderately emetogenic chemotherapy. There was more agreement between clinicians and guidelines for acute nausea/vomiting and less for delayed symptoms. The uptake of MASCC/ASCO guidelines was minimal.

CONCLUSIONS

The low level of agreement between actual clinical practice and evidence-based consensus guidelines may be one of the reasons for the considerable incidence of chemotherapy-related nausea and vomiting. There is a need to utilise consensus guidelines more widely and educate clinicians on this aspect of supportive care.