Complementary medicines in psychiatry: review of effectiveness and safety

BACKGROUND

The use of complementary medicines in those with mental health problems is well documented. However, their effectiveness is often not established and they may be less harmless than commonly assumed.

AIMS

To review the complementary medicines routinely encountered in psychiatric practice, their effectiveness, potential adverse effects and interactions.

METHOD

Electronic and manual literature search on the effectiveness and safety of psychotropic complementary medicines.

RESULTS

Potentially useful substances include ginkgo and hydergine as cognitive enhancers, passion flower and valerian as sedatives, St John's wort and s-adenosylmethionine as antidepressants, and selenium and folate to complement antidepressants. The evidence is less conclusive for the use of omega-3 fatty acids as augmentation treatment in schizophrenia, melatonin for tardive dyskinesia and 18-methoxycoronaridine, an ibogaine derivative, for the treatment of cocaine and heroin addiction.

CONCLUSIONS

Systematic clinical trials are needed to test promising substances. Meanwhile, those wishing to take psychotropic complementary medicines require appropriate advice.

Pharmacological treatments of cerebellar ataxia

The confirmed pharmacological treatment of cerebellar ataxia is still lacking. In a recent preliminary trial, we showed that D-cycloserine, a partial NMDA allosteric agonist, may relieve the symptoms. In this paper, major clinical trials to relieve ataxic symptoms are reviewed. Previous studies showed some efficacy of physostigmine in ataxic patients. However, physostigmine did not improve the ataxia in a recent double-blind crossover study. The replacement therapy of the deficient cholinergic system with choline or choline derivatives was tried in patients with Friedreich's ataxia and other ataxic patients, but the result was not definitive. A levorotatory form of hydroxytryptophan (a serotonin precursor), a serotoninergic 5-HT1A agonist, a serotoninergic 5-HT3 antagonist, and a serotonin reuptake inhibitor were also used for the therapy for ataxia. In a double-blind randomized study, buspirone, a 5-HT1A agonist was active in cerebellar ataxia, but the effect is partial and not major. The effects of the studies with the other serotoninergic drugs were not consistent. The effect of sulfamethoxazole-trimethoprim therapy in spinocerebellar ataxia type3/Machado-Joseph disease (MJD) was reported, although the therapy improved spasticity or rigidity, rather than ataxia. In contrast to previous studies, sulfamethoxazole-trimethoprim therapy in MJD had no effect in a 2001 double-blind crossover study. The thyrotropin-releasing hormone, D-cycloserine, and acetazolamide for SCA6 may have some efficacy. However, a well-designed double-blind crossover trial is needed to confirm the effect.

Use of cognitive enhancement medication in persons with Alzheimer disease who have a family caregiver: results from the Resources for Enhancing Alzheimer's Caregiver Health (REACH) project

OBJECTIVE

Aging populations show increased prevalence of cognitive impairment and dementia. Recent efficacy studies report on prescription medications and herbal preparations that affect cognitive functioning, but the prevalence and correlates of cognitive-enhancement (CE) medication use among community-dwelling older persons is not well studied. The authors examined the frequency and appropriateness of use, the importance of a family caregiver in medication decisions for dementia patients, and differences in access to medical care.

METHODS

REACH is a multisite feasibility study of several approaches to reducing the negative impacts of caregiving on those living with a family member with dementia. Data on medication use by care-recipients were collected at baseline and 1 year later.

RESULTS

At baseline, 31% of 1,222 care-recipients were using a CE medication. Factors independently related to CE use were age, education, functional status, and caregiver vigilance. Within 1 year, 14% started and 30% quit taking CE. Care-recipients more likely to be Starters had spouse-caregivers, more education, and fewer baseline ADL impairments. Quitters had more ADL deficits at baseline and became less able to perform ADL at follow-up than those who continued on CE.

CONCLUSIONS

CE medication use among dementia patients with a family caregiver is relatively common, though there is substantial geographic variability. Our findings are mixed with respect to appropriate use of CE medications, suggesting areas for physician education. Our data indicate the importance of the caregiver in CE medication use and suggest that there may be disparities in access to healthcare among people with cognitive impairment.

[Clinical study on effect of yuantong capsule in treating vascular dementia]

OBJECTIVE

To observe the clinical effect of Yuantong Capsule (YTC) in treating vascular dementia (VD).

METHODS

Eighty-three patients of VD were randomized on ratio of 2:1 into two groups, the 54 patients in the treated group were treated with YTC orally administered, 3 times a day, 1 capsule in each time. The remaining 29 patients in the control group were treated with Hydergine orally, 3 times a day, 2 mg in each time. The therapeutic course for both groups was 2 months.

RESULTS

The therapeutic effect in the treated group was significantly better than that in the control group, significant difference (P < 0.05 or P < 0.01) was shown in comparison of the two groups in terms of the mini-mental state examination (MMSE) and activity of daily living (ADL) test, symptoms scoring, total effective rate, and laboratory indexes findings.

CONCLUSION

The therapeutic effect of YTC in treating VD was obvious.

[Pathogenetic basis for using prodectin and teonicol, redergin and aescuzan in complex treatment of chronic gastritis]

The study of the microvessels in bioptates of gastric mucosa and micro haemocirculation in the conjunctiva of 254 patients with chronic gastritis revealed that exacerbation of the gastric process is going on the background of hard terminal bloodstream disorders. They have the generalized character and picture of the typical chronic relapsing trombohaemorrhagic syndrome. The use of Prodectin (250 mg), Teonicolum (150 mg), Redergin (1 tab.) and Aescuzan (25 dr.) 4 times per day during 3 weeks helps to eliminate the microcirculatory disorders and exacerbation of the chronic gastritis.

[Redergin treatment of hypertensive menopausal women]

AIM

To assess a hypotensive effect of redergin (dihydroergotoxin)--agonist of dopaminergic receptors--in monotherapy (4.5-6 mg/day) and in combination with enalapril and amlodipin (10 mg/day).

MATERIAL AND METHODS

Redergin in monotherapy or combined therapy was given to 106 hypertensive women in pre- or postmenopause and 24 hypertensive women of reproductive age. Antihypertensive effect was assessed by changes in arterial pressure, frequency and severity of hypertensive crises, diuresis, clinical symptoms of menopausal syndrome.

RESULTS

A significant fall in arterial pressure, intensive diuresis, less frequent or absent hypertensive crises, relief of menopausal symptoms were observed on day 10-14 of redergin monotherapy of menopausal patients with mild hypertension and in combined treatment of menopausal women with moderate and severe hypertension.

CONCLUSION

Antihypertensive and diuretic effect of redergin confirm a pathogenetic role of deficient dopaminergic activity in development of menopausal hypertension.

Alpha-dihydroergocryptine and predictive factors in migraine prophylaxis

OBJECTIVE

A double-blind, crossover study was carried out to compare the efficacy of alpha-dihydroergocryptine mesylate (10 mg twice daily) vs propranolol (40 mg twice daily) in the prophylaxis of migraine without aura, and to identify possible predictors of therapeutic response by evaluating the symptomatological profile of individual migraine attacks and the autonomic cardiovascular response to noradrenergic and dopaminergic (cold pressor, bromocriptine) tests.

PATIENTS AND METHODS

Forty migraineurs (10 males, 30 females) were randomized according to a two-period (3-month), two-treatment, crossover design. Efficacy was assessed using quantitative data recorded in the patient's headache diary. Data were evaluated using the Wallenstein's method.

RESULTS

Both drugs showed a significant reduction in all the efficacy variables (headache attacks, days with headache, analgesic consumption) with no difference between treatments. Neither a bromocriptine test, nor a cold pressor test nor the symptomatological profile of individual migraine attacks differed between the two groups of migraine patients. Ten patients experienced at least one adverse drug reaction during the first period of the crossover design, 5 being treated with alpha-dihydroergocryptine and 5 with propranolol.

CONCLUSIONS

It is concluded that alpha-dihydroergocryptine is an effective medication for migraine prophylaxis. The biochemical tests and the type of psychological profile cannot be used to predict drug response.

The effect of topically applied vasoactive agents and testosterone versus testosterone in the treatment of erectile dysfunction in aged men with low sexual interest

The objective was to evaluate the efficacy and safety of topically applied cream containing testosterone, isosorbide dinitrate and co-dergocrine mesylate compared to testosterone cream in the treatment of erectile dysfunction in aged men with low sexual interest. A randomised double-blind crossover trial was performed over two months. The subjects were 42 men with erectile dysfunction and low normal or slightly depressed testosterone level randomly allocated to two equal groups. Polypharmacy cream containing testosterone 0.8%, isosorbide dinitrate 0.5% and co-dergocrine mesylate 0.06% was applied for one month, and testosterone 0.8% cream for another month. The serum level of total testosterone was measured before and after each phase of treatment. Response to each therapy was assessed by a sexual questionnaire, measurement of tumescence and repeat penile duplex ultrasonography. Twenty-eight patients reported full erection and satisfactory intercourse with the polypharmacy cream. Thirteen men reported full erection and satisfactory intercourse with either cream. Polypharmacy cream increased penile arterial flow (P<0.001) and induced tumescence in 34 patients in lab. No patient in either phase of the study has tumescence or a significant increase in cavernous arterial peak systolic velocities after the application of testosterone cream. Serum level of total testosterone increased in all patients (P<0.05). Sexual desire was improved in 85% and 62% of patients during the treatment with polypharmacy cream and testosterone cream, respectively. No marked side effects were reported after either of them. Topical treatment with cream containing testosterone and vasoactive agents may represent a new effective treatment for erectile dysfunction associating with aging.

Hydergine for dementia

BACKGROUND

Currently hydergine is used almost exclusively for treating patients with either dementia, or 'age-related' cognitive symptoms. Since the early eighties there have been over a dozen more clinical trials, yet hydergine's efficacy remains uncertain. Although previous reviews offer generally favorable support for hydergine's efficacy, they were, however, limited by a bias with respect to the particular clinical studies chosen (eg, the inclusion of case reports, and uncontrolled trials), and by authors' impressionistic assessments of results. Not surprisingly, there has been a lack of consensus among reviewers with regard to the efficacy of hydergine. In 1994, a meta-analysis was published by the present reviewers who reported that overall, hydergine was more effective than placebo. However they also observed that the statistical evidence for efficacy in 'possible or probable Alzheimer's disease' patients was so modest that one additional statistically non-significant trial would have reduced the results to non significance.

OBJECTIVES

Because of uncertainty surrounding the efficacy of hydergine, the goals of this overview were to assess its overall effect in patients with possible dementia, and to investigate potential moderators of an effect.

SEARCH STRATEGY

The Cochrane Dementia Group Register of Clinical Trials was searched using the terms 'hydergine', 'ergoloids,' 'ergoloid mesylates,' 'dihydroergocristine,' 'dihydroergocryptine,' 'dihydroergotoxine,' and 'dihydroergocornine. MEDLINE, EMBASE, and two proprietary databases were searched also. Published reviews were inspected for further sources.

SELECTION CRITERIA

Trials to be included must be randomized, double-blind, parallel-group, and unconfounded comparisons of hydergine with placebo for a treatment duration of greater than 1 week in subjects with dementia or symptoms consistent with dementia.

DATA COLLECTION AND ANALYSIS

Data were extracted independently by the reviewers, pooled where appropriate and possible, and the pooled odds ratios (95%CI) or the average differences (95%CI) were estimated. Where possible, intention-to-treat data were used. Outcomes of interest included clinical global impressions of change and comprehensive rating scales. Potential moderating variables of a treatment effect included: inpatient/outpatient status, trial duration, age, sex, medication dose, publication year, and diagnostic grouping.

MAIN RESULTS

There were a total of nineteen trials that met inclusion criteria and that had data sufficient for analysis. Thirteen trials reported sufficient information to use a global rating of improvement and nine trials provided information on a comprehensive rating scale. Three trials provided both outcome measures. It was not possible to use many of the published results in a combined analysis owing to the lack of sufficient data to perform statistical analyses. For the twelve trials that used global ratings, there was a significant effect favoring hydergine (OR 3.78, 95%CI, 2.72-5.27). For the nine trials that used comprehensive ratings, there was a significant mean difference favoring hydergine (WMD 0.96, 95%CI, 0. 54-1.37). Hydergine was well tolerated in these trials, with 78% of randomized subjects available for data analyses. Greater effect sizes on global ratings were associated with younger age, and possibly higher dose, although most of the subgroup analyses were statistically insignificant.

REVIEWER'S CONCLUSIONS

As in an earlier systematic review, we found hydergine to show significant treatment effects when assessed by either global ratings or comprehensive rating scales (based here on a smaller set of trials than in the earlier published systematic review because trials were required to have data that could conform with MetaView, the Cochrane Collaboration statistics software). The small number of trials available for analysis, however, limited the ability of subgroup analyses to identify statistically significant modera

Inappropriate medication prescribing in homebound older adults

OBJECTIVES

Little is known about the prescribing of medications in the growing population of homebound older adults. We report on the prevalence and pattern of inappropriate medications in a nursing home-eligible, homebound population.

DESIGN

A cross-sectional design.

SETTING

A managed care plan for individuals meeting nursing home eligibility.

PARTICIPANTS

2193 homebound people older than age 60.

MEASUREMENTS

We reviewed the pharmacy profiles of all older homebound enrollees. We identified the average number of medications per patient and the most commonly prescribed classes of drugs. The medication profiles were also analyzed in the context of the 26 drugs/groups listed as inappropriate by the explicit criteria of Beers [Arch Intern Med 1997; 157:1531-1536].

RESULTS

A total of 2193 people aged 60 to 106 (mean 82.8 +/- 8.8) were taking an average of 5.3 +/- 2.9 drugs (range 0-22). Cardiac drugs and benzodiazepines were the medications most commonly prescribed. We found 1152 of the total 11,689 prescriptions (9.9%) to be inappropriate. Eight hundred seventy-one (39.7%) of these 2193 residents had at least one inappropriate prescription, and 230 (10.4%) had two or more. Of particular concern were 285 people prescribed excessive doses of temazepam and zoldipem, 211 people taking first-generation antihistamines, 115 taking doxepin or amitriptyline, 106 taking an ergoloid, 98 taking dipyridamole, and 85 prescribed a long-acting benzodiazepine.

CONCLUSIONS

Our study revealed a high prevalence of psychotropic medications and inappropriate drug use among older homebound residents, a group that is at the highest risk for adverse drug reactions. Because this group is not subject to oversight by regulatory agencies, further interventional studies and provider education will be important.

Pharmacologic management of Alzheimer disease, Part II: Antioxidants, antihypertensives, and ergoloid derivatives

OBJECTIVE

To provide information about research evaluating antioxidants in Alzheimer disease (AD) and to discuss the potential role of beta-blockers, angiotensin-converting enzyme inhibitors, clonidine, guanfacine, nimodipine, and ergoloid derivatives in AD therapy.

DATA SOURCES

Studies, review articles, and editorials identified from MEDLINE searches (from 1989 to 1997) and bibliographies of identified articles.

STUDY SELECTION

Studies and review articles addressing antioxidant, antihypertensive, and ergoloid derivative pharmacotherapy research.

DATA EXTRACTION

Pertinent information was selected and the data synthesized into a review format.

DATA SYNTHESIS

AD is a progressive neuropsychiatric disorder of unknown etiology. Studies evaluating the possible association between a free radical mechanism in AD and the potential role of antioxidants are reviewed. Additionally, the role of beta-blockers, angiotensin-converting enzyme inhibitors, clonidine, guanfacine, nimodipine, and ergoloid derivatives in AD management are discussed.

CONCLUSIONS

Preliminary evidence suggests that antioxidants may have a protective effect against the development of AD. Additional prospective, double-blind, placebo-controlled studies are needed to determine the role of antioxidants in the prevention and management of AD. Understanding the role of antioxidants in AD may suggest alternative agents that have similar pharmacologic activity. Beta-blockers may be an option to control agitation in AD patients for whom anxiolytics or antipsychotics are ineffective or are contraindicated because of their adverse effect profiles. Other agents that may have a role in AD therapy include angiotensin-converting enzyme inhibitors, nimodipine, and ergoloid derivatives. Clonidine and guanfacine have thus far shown little promise in improving cognitive function in AD. Further prospective, double-blind, placebo-controlled trials will be necessary to elucidate the role of these agents in AD management.

New drugs for Alzheimer's disease

Alzheimer's disease is characterized by degeneration of various structures in the brain, with development of amyloid plaques and neurofibrillary tangles. Deficiencies of acetylcholine and other neurotransmitters also occur. Pharmacologic treatment of the disease generally seeks to correct the histopathology, the biochemical derangements or their effects. The only drugs labeled to date for the treatment of cognitive symptoms in patients with Alzheimer's disease are two cholinesterase inhibitors that prevent the breakdown of acetylcholine in the synapse. Both medications are associated with modest improvements in cognitive function. However, all benefit is lost when these drugs are discontinued; the disease then progresses to the level seen in placebo-treated patients. Tacrine, the first cholinesterase inhibitor to be so labeled, must be taken four times daily and is associated with hepatic toxicity. Donepezil is taken once daily. Side effects of the cholinesterase inhibitors include nausea, vomiting and diarrhea, which tend to subside after the titration period. Other drugs that have shown some promise in the treatment of Alzheimer's disease are vitamin E, estrogen, selegiline and a mixture of ergoloid mesylates. Anti-inflammatory drugs and nicotine are also being studied for their effects as neuroprotectors or neurotransmitter enhancers. The caregivers of patients with Alzheimer's disease may see little effect from these or other investigational agents, but nursing home placement may be delayed.

Drug treatment of Alzheimer's disease. Effects on caregiver burden and patient quality of life

Alzheimer's disease is a devastating illness that will become more common as the population ages. Although clinical diagnosis of the illness is not certain without histological examination of the brain, and misdiagnosis may occur, broad working criteria to help diagnose the likely presence of Alzheimer's disease are available. Thoughtful clinical evaluation improves diagnostic accuracy, and appropriately diagnosed patients are critical for involvement in research into new antidementia agents. Essential to the discovery of new drugs is careful measurement of illness response. A variety of scales--some aimed at patients, others at their caregivers, and yet others for clinicians--assess Alzheimer's disease severity, progression, symptom response, and quality of life. Of note, patient response is not the only measurement of treatment benefit today. Growing interest is also being placed on tracking the possible amelioration of caregiver 'burden'. This burden refers to the psychological, physical, and material costs of providing care for an Alzheimer's patient over long periods of time. A number of scales and questionnaires have been developed and are occasionally used. Many drugs have been tried in Alzheimer's disease, but very few have produced any benefit, and this is often modest. Ergoloid mesylates, initially thought to be effective, are now considered of little value. The cholinomimetic drugs, especially the acetylcholinesterase inhibitor tacrine, have provided a very modest benefit, slowing the progression of the illness for a number of months. No cognitive improvement has been noted with the various nootropic agents such as piracetam. Early studies with levacecarnine (acetyl-L-carnitine), a substance that facilitates the use of fatty acids, memantidine, the dimethyl derivative of amantidine, and the calcium channel blocker nimodipine, have shown some promise, but require larger, more rigorous studies. As mentioned above, documenting effects in individual patients is crucial; examining for potential benefit to caregivers is a growing part of research design. Current treatment efforts will become more sophisticated as a deeper understanding of the neurobiology of Alzheimer's disease develops. For the immediate future, the goal is not cure but slowing of the disease process. Achieving this limited goal would have a substantial impact on the financial and human costs of the illness.

Ergoloids and ischaemic strokes; efficacy and mechanism of action

In this double-blind, randomized study the efficacy of the ergoloid compounds, co-dergocrine mesylate and nicergoline, in the rehabilitation of patients with ischaemic stroke was investigated. A group of 30 patients was treated daily with 60 mg nicergoline, orally, and a second group of 27 patients was given 1.8-6 mg co-dergocrine mesylate, orally or intramuscularly, daily (depending on the time since the initial ischaemic insult) for 6 months. Outcome measures included: motoricity index (limb function); Sandoz Clinical Assessment Geriatric (SCAG) scale; psychometric tests to assess functions such as attention, psychomotor performance, perception and sensory and short-term memory; conventional and computerized electroencephalography; and P300 and reaction time measures. The results showed improvements in some aspects such as limb function (P < 0.05), SCAG score (P < 0.01) and some electrophysiological parameters (P < 0.01) after treatment with both drugs. Though statistically significant most of the changes were not large. The efficacy of both drugs was qualitatively similar. The quantitative difference in some aspects in favour of nicergoline could be attributed to differences in the mechanisms of action of the two drugs, although it is also possible that the difference may reflect the dosages used. Nootropic drugs may induce a condition that facilitates the effects of cognitive training.

Overview of clinical trials of hydergine in dementia

OBJECTIVE

To assess the overall effect of Hydergine (a combination drug called ergoloid mesylates) on patients with possible dementia and to investigate potential moderators of an effect.

DATA SOURCES

MEDLINE, EMBASE, and two proprietary databases were searched for reports of clinical trials.

STUDY SELECTION

Included were randomized, placebo-controlled, double-blind, parallel-group trials in subjects with symptoms consistent with dementia performed with specified outcome instruments and sufficient statistical information to calculate effect sizes. Forty-seven (31%) of 151 trials reviewed met selection criteria.

DATA EXTRACTION

Potential moderating variables were extracted from each trial: sample size, inpatient-outpatient status, trial duration, age, gender, medication dose, publication year, and diagnostic grouping. Outcome measures were extracted with their associated statistics.

DATA SYNTHESIS

The overall combined treatment effects ("adjusted d") for three types of outcome measures were calculated. Overall, Hydergine was more effective than placebo as assessed by comprehensive ratings (d = 0.47; 95% confidence interval [CI], 0.38 to 0.56; P = .0001), clinical global ratings (d = 0.56; 95% CI, 0.44 to 0.68; P = .0001), and combined neuropsychological measures (d = 0.27; 95% CI, 0.22 to 0.32; P = .0001). Inpatient status, daily doses of 4 mg or more, and vascular dementia were generally associated with larger effects. The effect in patients with possible Alzheimer's dementia was significant only for combined neuropsychological measures in five trials (d = 0.30; 95% CI, 0.16 to 0.44; P = .0001; and with a dose-response, P = .001).

CONCLUSIONS

Overall, ergoloid mesylates were more effective than placebo. However, the effect in patients with possible Alzheimer's dementia was very modest at best. The dose-response relation suggests that potentially effective doses may be higher than the currently approved. The circumstances of the efficacy of Hydergine remain inadequately defined.

Ginkgo biloba for cerebral insufficiency

1. By means of a critical review we tried to establish whether there is evidence from controlled trials in humans on the efficacy of Ginkgo biloba extracts in cerebral insufficiency. 2. The methodological quality of 40 trials on Ginkgo and cerebral insufficiency was assessed using a list of predefined criteria of good methodology, and the outcome of the trials was interpreted in relation to their quality. A comparison of the quality was made with trials of co-dergocrine, which is registered for the same indication. 3. There were eight well performed trials out of a total of 40. Shortcomings were limited numbers of patients included, and incomplete description of randomization procedures, patient characteristics, effect measurement and data presentation. In no trial was double-blindness checked. Virtually all trials reported positive results, in most trials the dosage was 120 mg Ginkgo extract a day, given for at least 4-6 weeks. For the best trials, there were no marked differences in the quality of the evidence of the efficacy of Ginkgo in cerebral insufficiency compared with co-dergocrine. The results of the review may be complicated by a combination of publication bias and other biases, because there were no negative results reported in many trials of low methodological quality. 4. Positive results have been reported for Ginkgo biloba extracts in the treatment of cerebral insufficiency. The clinical evidence is similar to that of a registered product which is prescribed for the same indication. However, further studies should be conducted for a more detailed assessment of the efficacy.

Co-dergocrine mesylate. A review of its pharmacodynamic and pharmacokinetic properties and therapeutic use in age-related cognitive decline

Co-dergocrine mesylate is a combination of the mesylated forms of dihydroergocornine, dihydroergocristine, dihydro-alpha-ergocryptine and dihydro-beta-ergocryptine. In animal models and healthy elderly volunteers the compound improves indices of cognitive function such as memory and learning. The mechanism(s) behind such action remains under investigation. Nonetheless, it has been proposed that co-dergocrine mesylate has a dual effect on central monoaminergic neurotransmitter systems, compensating for both hyperactivity and deficits of the adrenergic, serotoninergic and dopaminergic systems. The compound also appears to have a normalising effect on the power of electroencephalogram frequencies, and may improve cerebral metabolism. Results from controlled studies of elderly patients with age-related cognitive decline have established that co-dergocrine mesylate is well tolerated and, in some studies, had statistically significant positive effects on symptoms of cognitive dysfunction. However, there is considerable controversy over the clinical relevance of these results as there was wide variability in the number and type of cognitive and neuropsychological assessments used in individual studies and there may have been considerable overlap in diagnosis of patients with varying degrees of dementia. In addition, the drug has not been compared with most other, more recently developed, centrally active agents. Thus, the specific place of co-dergocrine mesylate in the treatment of age-related cognitive decline remains undetermined, despite many years of clinical use.

Co-dergocrine plasma concentrations and blood pressure changes in hypertensive patients during therapy with slow-release co-dergocrine mesylate

In a placebo controlled trial in 20 patients (mean age 38 years) with mild/moderate essential hypertension 4.5 mg slow-release co-dergocrine mesylate was administered once daily for 6 weeks and antihypertensive effects and plasma co-dergocrine concentrations determined 9 hours post-dose. Mean plasma co-dergocrine concentrations were 299 pg/ml, 357 pg/ml and 331 pg/ml measured after 2-, 4-, and 6-weeks administration respectively. Despite these relatively low concentrations there were statistically significant reductions in supine (-6/-6 mmHg), standing (-9/-8 mmHg) and exercise (-8/-5 mmHg) systolic and diastolic blood pressure. Blood glucose fell progressively and was 10% lower (p less than 0.02) after 6 weeks medication. Clinical and laboratory parameters showed that slow-release co-dergocrine mesylate was well tolerated with negligible adverse reactions.

[Effect of hydrogenated ergot alkaloids on cerebral metabolism of the patients with neurological deficits after subarachnoid hemorrhage (author's transl)]

Cerebral blood flow and metabolism were measured in 9 patients with neurological deficits after subarachnoid hemorrhage using the 133Xe intra carotid injection methods. Regional cerebral blood flow (r-CBF) values were calculated with initial slope method (2 minutes flow index), their values were compared with the blood flow response to arterial PCO2 and to administration of hydrogenated ergot alkaloids (HEA). In case of repeated examination after short interval CBF values were corrected using the rate of reproducibility. The content of oxygen, glucose, lactate, and pyruvate in the arterial and the internal jugular blood were measured , and CMRO2, CMR glucose, CMR lactate, values were calculated: 1st step: The measurement of r-CBF was performed immediately after the infusion of 1.5 mg HEA for 15 minutes. The focal ischemic lesions decreased, mean CBF value increased by 8% significantly, arterio-venous difference of oxygen value increased by 20% significantly and CMRO2 value increased by 26% significantly after HEA administration. 2nd step: 1.8 mg HEA was infused for one week. EEG findings were improved after administration of HEA. The pressure and the lactate levels of cerebrospinal fluid decreased, but the effect of HEA must be carefully distinguished from natural recovery. Administration of HEA increased the CMRO2 values and consequently increased the mean CBF values.

An ergot alkaloid preparation (Hydergine) in the treatment of dementia: critical review of the clinical literature

A critical review is presented of 12 clinical trials with Hydergine (a hydrogenated ergot alkaloid preparation) in the treatment of dementia. Qualitative and quantitative comparisons of improvement in symptoms showed that Hydergine consistently produced statistically significant (p less than or equal to 0.05) improvement in 13 symptoms associated with dementia. However, because of the small magnitude of the improvement and the absence of indications of long-term benefit, Hydergine would seem to be of minor value in dementia therapy. Further research with better methodology and design might lead to a different conclusion.

[The effects of dihydroergo-corine,-cryptine and-cristine on Haemodynamics in experimental cardiogenic shock]

Experimental results demonstrate, that serial ligatures of the side brances of the anterior descending and circumflex artery in the openchest dog produce a hemodynamic and electrocardiographic criteria fullfilling cardiogrenic shock. The application of the alpha-receptor-blocking agens Hydergin is followed by a statistically significant increase of the mean aortic pressure, the left ventricular systolic pressure and the mean blood flow in the femoral artery. The left ventricular enddiastolic pressure in the left ventricular enddiastolic pressure in the left ventricle decreases statistically not significant, dp/dtmax is unchanged. Hydergin effects a slope of the increased peripheral vascular ristance; if the peripheral vascular risistance is lowered during cardiogenic shock, there will not be a further lowering after treatment. The results show, that Hydergin causes a dilation of peripheral vasoconstricted vessels without unwanted hemodynamic side effects.

[The effect of an antihypertensive drug during psychological stress. A double-blind study]

A sample of 20 patients suffering hypertension (with a moderate rise in blood pressure) was randomly divided into two treatment groups of equal size. The patients of one group received antihypertension treatment with the combination drug Briserin¿ (containing 0.1 mg reserpine, 5 mg clopamide, 0.5 mg dihydroergocristin/per tablet); the other patients who served as control group, received a matched placebo. After a fortnight's treatment, the responsiveness of both groups to five different psychologically stressing situations (those with cognitive and/or emotional overload) was tested. Analysis of covariance revealed clinically significant differences in the mean systolic and diastolic pressure scores of the two groups. The scores of the treatment group were lower not only under stress but also at rest. There was in interaction between rise of blood pressure under stress and kind of stress in the two groups, i.e., in situations with heavy emotional and/or cognitive load the differences in the pressure scores of the two groups were less substantial than in situations with a low or medium load. The treatment had no systematic effect on heart rate in this sample. In the treatment group reaction time, perceptual speed, and short-term memory were impaired as compared with the control group; but these differences did not reach a level of significance.

Mental decline in the elderly: pharmacotherapy (ergot alkaloids versus papaverine)

This is the first double-blind study in outpatients to evaluate the effectiveness of dihydrogenated ergot alkaloids (DEA) (Hydergine) versus papaverine in the treatment of selected symptoms associated with mental aging. In addition, this is the first study comparing these two pharmacologic agents in relatively young geriatric patients, with a mean age in the mid-sixties. After twelve weeks of treatment, ratings of overall clinical condition and global change showed that the 26 patients given DEA improved more than twice as much as the 27 patients given papaverine. Of the 14 individual symptoms rated, 13 improved significantly more in the DEA group than in the papaverine group. These symptoms included confusion, dizziness, unsociability, depressive mood, and mental alertness. Other data confirmed the generally superior results with DEA. In view of its demonstrated beneficial clinical actions and of its notable scarcity of contraindications or side effects, DEA appears to represent a significant pharmacologic contribution to the care of elderly persons showing selected symptoms of mental and functional decline.

The use of psychoactive drugs in elderly patients with psychiatric disorders: survey conducted in twelve Veterans Administration hospitals

A survey conducted at 12 VA hospitals included the collection of detailed information on the use of psychoactive drugs in 1,276 elderly psychiatric patients. On the day of the survey, 61 per cent of the patients were receiving psychoactive drugs. Prescription practices relating to the choice of drugs, prevalence of drug use, dosage, combination drug preparations, and antiparkinson agents are discussed in terms of such factors as the patient's age and the diagnosis. Also discussed is the literature on psychoactive drugs, particularly as it pertains to elderly populations.