Pharmacokinetic and pharmacodynamic studies following the intravenous and oral administration of the antiparkinsonian drug biperiden to normal subjects

The pharmacokinetics and pharmacodynamics (changes in pupil size and salivary flow) of biperiden following a single oral and intravenous dose were investigated in six normal subjects. After the injection plasma concentrations declined biphasically, with half-times of 1.5 h for the rapid phase and 24 h for the terminal phase. Clearance and apparent volume of distribution were high (12 ml X min-1 X kg-1 and 24 l X kg-1 respectively). Absorption was rapid but the systemic availability was incomplete (33%), probably due to first-pass metabolism. Central nervous system (CNS) adverse effects and changes in pupil size were observed after both routes of administration while salivary flow was affected only by the injection.

Antiparkinsonian medication withdrawal in the treatment of tardive dyskinesia: a report of three cases

Three patients are presented in whom TD either disappeared (2 cases) or improved (one case) after discontinuing antiparkinsonian medication without changing the concurrent neuroleptic treatment. In addition, two of the patients presented some "complications" secondary to the TD in the form of frequent falling, psychosocial impairment and suicidal ruminations. The implications of these findings are discussed in the light of the current literature.

[Clinical study of pergolide in Parkinson's disease]

Pergolide is thought to stimulate both D1 and D2 dopaminergic receptors. Its effects on Parkinson's disease were evaluated in an open trial, using clinical assessment scales and objective tests. Nine patients had previously been treated with L-dopa, but the drug had either gradually lost its effectiveness or produced invalidating side-effects. Pergolide in doses of 2 mg per day considerably and durably improved the parkinsonian symptoms and enabled the patients to reduce L-dopa dosage by about 50%. Dyskinesia and "on-off" phenomena partially regressed. Significant improvement was also observed in 3 of 4 patients with Parkinson's disease who had not previously received L-dopa. The side-effects of pergolide were fairly frequent in both groups, but they were relatively mild and reversible.

Long-term experience with pergolide therapy of advanced parkinsonism

Nine patients with idiopathic Parkinson's disease were treated with pergolide to a daily maintenance dose of 2.2 +/- 0.9 mg (mean +/- SD) for 17.3 +/- 8.3 months. After 1 month, there was an average 68% increase in mobile on-time, but the improvement declined to 30% by 6 months, 23% by 1 year, and virtually disappeared by 18 months of therapy. Pergolide was discontinued in seven patients because of loss of efficacy (4 patients), confusion (1 patient), or myocardial infarction or ventricular ectopy (2 patients). Partial but temporary restoration of mobility was observed in seven patients who were switched to an alternate-day dosing schedule after 9.2 +/- 2.4 months. Two patients with advanced Shy-Drager syndrome were treated with pergolide without benefit.

Mesulergine (CU32-085) in the treatment of Parkinson's disease

Twenty patients with Parkinson's disease were treated with the 8-alpha-ergoline derivative mesulergine. Participants were divided into two groups, and over a nine-week period, mesulergine dosage was increased to a maximum of either 10 or 20 mg daily. During this time levodopa-carbidopa (LD-CD) dosage was reduced and treatment was discontinued if possible. The dosage of LD-CD was reduced 75% in the 10 mg group and 74% in the 20 mg group. Patients in the low-dose group maintained their functional status and showed improvement in postural stability. Patients in the high-dose group showed improvement in each of the cardinal signs of parkinsonism. Adverse effects were generally mild and infrequent. Many adverse effects induced by LD-CD diminished or resolved. Our results suggest that mesulergine can be valuable in the management of Parkinson's disease, particularly in those individuals experiencing dose-limiting adverse effects from LD-CD.

Placebo-controlled study of mesulergine in Parkinson's disease

We used a new D2 dopamine agonist, mesulergine (8-alpha-amino-ergoline, CU 32-085), to treat 20 patients (12 men and 8 women), mean age 62.6 (SEM = 1.7) and mean duration of illness 5.9 (SEM = 1.0) years. Wearing-off effect was the principal indication for new therapy in 15 patients, and the others had inadequate response to levodopa. All continued on levodopa therapy, and 10 patients were studied in a double-blind controlled test. The mean motor disability decreased from 2.8 (SEM = 0.12) to 1.6 (SEM = 0.18) with mesulergine (p less than 0.0001) and increased to 1.9 (SEM = 0.20) with placebo (p less than 0.001). Tremor improved most, followed by rigidity, bradykinesia, gait, and postural instability. Side effects included dyskinesia, light-headedness, hallucinations, nausea, vomiting, drowsiness, and ankle edema, but, in general, mesulergine was tolerated well.

Pharmacotherapy of chronic hospitalized schizophrenics: prescription practices

Prescription practices were examined as part of a multinational study of chronic hospitalized schizophrenic patients. The study included a total of 768 patients from 8 countries. All patients had a diagnosis (ICD-9) of schizophrenia and met defined criteria for chronic hospitalization. The patients were treated with psychotropic drugs from 6 categories, i.e., neuroleptics, antidepressants, lithium salts, anxiolytics, anticonvulsants, and antiparkinsonian medications, as well as with a variety of nonpsychotropic drugs. The majority of the patients received concurrently more than 1 neuroleptic, medications from 2 or more categories, and neuroleptics combined with other agents. Polypharmacy appeared to be universal in this population.

Controlled-release carbidopa/levodopa in the treatment of Parkinsonism

Controlled release carbidopa/levodopa (CSR-1) was compared to standard carbidopa/levodopa in a double-blind, crossover study of 20 Parkinson's disease patients. The most consistent finding in a variety of clinical measurements was the superiority of standard carbidopa/levodopa to CSR-1. Increased dosages of CSR-1 resulted in reduced Parkinson symptoms, suggesting that a more potent controlled-release formulation might prove to be more efficacious than CSR-1.

Psychotropic drugs: another survey of prescribing patterns

We surveyed the psychotropic drug treatment of our hospital's 220 patients, and compared our findings with those of the only previous hospital survey in this country which showed much allegedly inappropriate prescribing. Using simple classifications of the patients' diagnoses and of the drugs prescribed, 30 per cent of our prescriptions appeared inappropriate in the absence of knowledge of the patients' symptoms. With such knowledge we show that only 2 of our 460 prescriptions were inappropriate.

Limitations of long term use of antiparkinson drugs

Effective control of parkinsonian symptoms can be achieved in a substantial number of patients by the judicious use of dopaminergic agents. To a considerable extent these drugs produce optimal therapeutic effects during the first 3-5 years of their use. Subsequently, efficacy diminishes with reemergence of parkinsonian symptoms as well as a number of untoward responses. The nature, frequency and mechanisms underlying the limitations of long term use of presently available anti-parkinson agents are discussed in this presentation.

Psychotropic drug prescription in Nigeria

A study of prescribing practice in three psychiatric institutions in Nigeria revealed high frequency of polypharmacy liberal routine use of antiparkinsonian agents and daily multiple administration of drugs. In the treatment of depression and schizophrenia older and better known oral neuroleptics were preferred to newer ones, but there was apparent tendency for depressives to be under-treated and long-acting depot preparations were seldom administered to schizophrenics. Several aspects of drug use were similar to those observed elsewhere, particularly in the Anglo-American practice - an observation presumed explicable in terms of common psychiatry training background. The need for clinicians to comply with acceptable pharmacokinetic principles of drug treatment is stressed.

Dyskinesias in the geriatric population

In a population of 500 British geriatric nursing home patients, dyskinesias were assessed using the Abnormal Involuntary Movement Scale. The prevalence of spontaneous dyskinesias was 13.2%, whereas 22.1% of patients receiving neuroleptics medication demonstrated dyskinesias. The frequency was greater in male patients (21.2%) than in female patients (13.2%). Conjoint treatment with antipsychotic and antiparkinsonian medication resulted in the greatest prevalence of abnormal movements (40.6%). The average age of the study population was 82.6 years, and there was no trend for greater frequencies of dyskinesias according to age.

Treatment of Parkinson's disease with 8-alpha-amino-ergoline, CU 32-085

8-alpha-amino-ergoline (CU 32-085) is a dopamine receptor agonist that should have fewer side effects than most other dopamine agonists. We studied the effect of this drug in 19 parkinsonian patients. In untreated or levodopa-treated patients, there was considerable improvement of akinesia, rigidity, and tremor; on-off symptoms also improved in the levodopa-treated patients. In patients pretreated with levodopa/bromocriptine, about half the dose of CU 32-085 was necessary to obtain the same therapeutic results, but there was no further improvement of on-off symptoms. Side effects were less pronounced than with bromocriptine; no circulatory disturbances and no psychotic episodes were observed.

Monitoring drugs in hospitals for the mentally handicapped

The systematic application of guidelines derived from the British National Formulary resulted in a substantial reduction of the amount and frequency of medication used in two hospitals for the mentally handicapped.

"Long term evaluation of combined treatment of Parkinson disease with L-dopa, peripheral decarboxylase inhibitors and bromocreptine"

In this study the author's experience of Parkinson Disease treatment with long-term Bromocriptine (Br) administration, is summarized. Br, which acts directly on dopaminergic receptors, was introduced in combination with L-Dopa and peripheral decarboxylase inhibitors (PDI). The reasons for this association were: 1) the reduced effectiveness of the current treatment (L-Dopa + PDI) 2) onset of AIM (abnormal involuntary movements). 3) patient's desire to try new drugs. Only the patients who had been on the triple association for at least a year, were considered. Therefore of 50 patients originally considered only 19 were included in this study. The addition of Br allowed a reduction of the mean daily dose of L-Dopa(30%) and the therapeutic efficacy of the drug remained unchanged even after more than 4 years treatment. The "on-off" effect and AIM, are reduced by Br especially in the first months of treatment. The triple association is regarded at present as the best treatment for Parkinson disease.

Weekly drug holiday in Parkinson disease

Patients with Parkinson disease and drug-related side effects entered an open-trial study in which they stopped all dopaminergic medications for 2 consecutive days each week. Nine of 17 patients could tolerate the cessation of dopaminergic medication, and all of them showed improvement of side effects during the drug holiday and often throughout the week. Patients who could not tolerate withdrawal of medication were identified within 3 weeks by increased tremor or bradykinesia. This at-home drug holiday offers a potential therapy applicable to large numbers of parkinsonian outpatients who suffer progressive drug-related side effects.

Gradual withdrawal of antiparkinson medication in chronic schizophrenics: any better than the abrupt?

Twenty-four months after the completion of a double blind study of antiparkinson (AP) medication abrupt withdrawal in which 100 chronic schizophrenics took part, 42 patients out of that study's 75 patient placebo group were found in the ward. In a new double blind 8-week study of 3-week gradual withdrawal of AP medication, 70-6 per cent of the 34 patient placebo group (vs. none of the active) presented severe extrapyramidal symptoms (EPS) necessitating early termination, 23.5 per cent (vs. 12.5 per cent of the active) presented worsening but not to a point necessitating early termination, and only 5.9 per cent (vs. 87.5 per cent of the active) completed the 8-week period unchanged. Furthermore, 41.17 and 23.52 per cent of the placebo group (vs none of the active) presented EPS-related severe complaints and or psychotic symptomatology, respectively. These results were almost identical to those of the study of abrupt withdrawal. Thus, it seems that AP medication withdrawal in chronic schizophrenics remains problematic, even if the medication is withdrawn gradually.

[Pathogenetic treatment of various hereditary extrapyramidal disorders with new drugs]

The authors report the results of treatment of hereditary extrapyramidal diseases with new preparations acting upon neurotransmitter systems. Patients with torsion dystonia, Huntington's chorea, Parkinson's disease, hereditary tremor, myoclonic epilepsy were followed-up for several years.. The best results in akinetic-rigidity syndromes (Parkinson's disease, rigid froms of torsion dystonia, Hallevorden-Spatz disease) were obtained with L-DOPA (including Sinemet, Nacom, Madopar) and in many patients these preparations were given in combination with other drugs (cholinolytic agents, Midantan) which contributed to compensation of the disturbed equilibrium of neurotransmitter systems and reduction of side effects. For decreasing the side effects of L-DOPA (hyperkineses of dystonic type, chorea and myoclonia) preparations from the group of phenothiazine and diazepine were given. In many cases improvement was achieved by slover increase of L-DOPA doses. In the hyperkinetic syndromes (Huntington's chorea, idiopathic tremor, myoclonic epilepsy, hyperkinetic torsion dystonia) preparations of phenothiazine, butyrophenone and new drugs active on the GABAergic system (Baclophen, Lyoresal, Pantogam) and diazepine (Clonazepam) were used. The analysis of the results shows that disturbed equilibrium of central neurotransmitters plays and important role in the pathogenesis of hereditary extrapyramidal system diseases.

[L-dopa with inhibitor in the treatment of parkinsonian syndrome-results of long-term observations]

The report is based on the observation of 39 patients with parkinsonian syndromes treated with L-DOPA with inhibitor, including 30 patients treated during 2-6 years. It was found that treatment with L-DOPA with the inhibitor gave good or very good results in most patients with these syndromes with a relatively good drug tolerance during the first three months. With passing time the effect of the drug on the manifestations of the disease decreases and the tolerance becomes aver worse. The results of the treatment are worse although the applied daily dose is increased by a metan value of 50%. AT the same time the frequency of such complications as hyperkineses, anxiety and depression labyrinthine-cerebellar signs increases. Urinary passage disturbances and mental degradation develop and their temporal association with L-DOPA treatment is unquestionable, while a cause-and-effect correlation seems likely. In the conclusion the author suggests the need for a careful consideration of each decision of treatment with L-DOPA, and the possibility of improving the results of parkinsonism treatment is seen in the production of new optimal forms of he already present drugs, monitoring blood drug levels, and practical utilization of the synergism between the group of drugs stimulating the dopaminergic system and the group of drugs inhibiting the acetylcholinergic system.

Changes in the prescription of anticholinergic drugs (1970-1977) in a state hospital

A study of the prescribing patterns of physicians in a state hospital during 1970-1977 revealed a four-fold drop in the use of combinations of drugs with strong anticholinergic properties. This dramatic shift to more rational practices stands in contrast to reports of persistent inappropriate prescribing in other settings. The time pattern of the changes suggests that an active ongoing educational program combined with a drug monitoring system providing feedback to physicians was primarily responsible for the findings. This study clearly documents the fact that physicians' prescribing patterns are amenable to change in the direction of more appropriate practices.

[Two cases of buccolingual dyskinesia treated with tiapride (author's transl)]

Two patients with Parkinson's disease developed buccolinguo-facial dyskinesias which were greatly improved after tiapride administration in association with antiparkinsonian agents.

[Drugs and indications for medical treatment in Parkinson's disease (author's transl)]

The authors present a review of the actual drugs efficient in the treatment of Parkinson's disease. They emphasize the frequency of the side-effects and consequently to the difficult management of Parkinsonism. The indications are schematically summed up.

Bromocriptine associated with a peripheral dopamine blocking agent in treatment of Parkinson's disease

A peripheral dopaminergic blocking agent, domperidone (60 mg daily), or placebo was given, double-blind, to 17 parkinsonian patients who also received increasing doses of bromocriptine. Combined treatment with domperidone reduced total disability by 76% in 8 patients receiving a mean dose of 148 mg of bromocriptine daily. There was no vomiting and involuntary movements and psychic disturbances were similar to those in patients on levodopa and a peripheral decarboxylase inhibitor. In 9 patients taking placebo instead of domperidone, the average daily dose of bromocriptine could not be raised beyond 92 mg. The mean total disability score in this group was reduced by only 48%. Thus, peripheral blockade of dopamine receptors is a promising means of limiting the adverse side-effects of the treatment of parkinsonism with central dopaminergic receptor stimulating agents such as bromocriptine.

Therapeutic antagonism between anticholinergic antiparkinsonism agents and neuroleptics in schizophrenia. Implications for a neuropharmacological model

Systematic data from three studies suggest that anticholinergic antiparkinsonism agents, when added to ongoing neuroleptic treatment in schizophrenics, have the effect of arresting or reversing therapeutic changes, and when given alone to untreated patients, tend to further worsen their psychosis. The countertherapeutic effects of anticholinergic drugs are reflected particularly in parameters which represent features of schizophrenic psychosis most consistently responsive to neuroleptics. It is proposed that these anticholinergic effects are central in origin and point to the involvement of cholinergic mechanisms in the expression of schizophrenic psychosis and its improvement with neuroleptic medication.

Antiparkinsonian drug doses and neuroleptic receptors

The clinical potency of 3 drugs, apomorphine, N-propylnorapomorphine, and bromocryptine, have been found to be closely correlated to their potencies in competing for 3H-haloperidol and 3H-spiroperidol both of which label the dopamine receptor. This correlation indicates that the direct binding assay may be used to predict clinical potencies of anti-parkinsonian drugs, and indicates that agonists as well as antagonists compete potently for 3H-neuroleptic binding.

Drug monitoring at an Australia depot phenothiazine clinic

Three aspects of treatment with injectable neuroleptics, are presented. An individualized approach to the dosage of Fluphenazine decanoate must be practiced in conjunction with, and taking into account the time spent in treatment and the sex and age variables reported. Our flexible approach to the interval between injections, indicated a large group could be maintained at intervals of 5 to 8 weeks. Complex and challenging problems can be found with antiparkinsonian drugs; 30% of nearly 400 outpatients still require these drugs.

A survey of tardive dyskinesia in psychiatric outpatients

The authors found a high prevalence--43.4% of tardive dyskinesia in a sample of psychiatric outpatients, a population previously thought to be at nominal risk for development of this syndrome. There was no significant relationship between the presence of dyskinesia and age, sex, years of neuroleptic use, or various organic factors. The effects of dentures and of drug combinations are discussed, and it is noted that structured scales of dyskinesia and videotope recordings are important tools in diagnosing and following the course of dyskinesia.

Influence of the antiparkinsonian drugs on the plasma level of neuroleptics

The interaction between various neuroleptics and antiparkinsonian drugs was analyzed by measuring the neuroleptic plasma level before and after withdrawal of antiparkinsonian drugs. The population completing the study consisted of 32 chronic schizophrenics treated with chlorpromazine (8), levomepromazine (14), thioridazine (6), or haloperidol (4). Twenty-five were also receiving benztropine; 4, trihexyphenidyl; and 3, procyclidine. During the first 4 weeks patients remained on neuroleptics and antiparkinsonians, the latter being withdrawn during the 5th week, and the neuroleptics alone being administered during 16 following weeks. The plasma level of neuroleptics was assayed by gas liquid chromatography, once weekly in the morning at two different times. The analysis of variance showed a significant difference in neuroleptic plasma level when patients took neuroleptics only versus the period they had received neuroleptics and antiparkinsonians. The multiple comparison based on Studentized range Q0-05 revealed a significant progressive increase of neuroleptic plasma level during 12 weeks after withdrawal of antiparkinsonian drugs after which a plateau was reached. The hypothetical mechanisms of action of antiparkinsonians on neuroleptic plasma level are discussed.

Antiparkinsonian agents and long-term neuroleptic treatment. Effect of G 31.406, orphenadrine, and placebo on parkinsonism, schizophrenic symptoms, depression and anxiety

The need for medication with anticholinergic antiparkinsonian drugs was examined in 118 schizophrenic patients under long-term neuroleptic treatment. It was found that 1) none of 18 patients under treatment with low mg potency neuroleptics (chlorprothixene, clozapine, and thioridazine) had any need for anticholinergics; 2) of 60 patients under treatment with short-acting high mg potency neuroleptics (perphenazine greater than 16 mg daily and haloperidol greater than 2 mg daily) nine patients (15%) required medication with anticholinergics, whereas 3) of 40 patients under treatment with long-acting (depot) neuroleptics, 17 (43%) had a need for anticholinergic medication; and 4) no patient factors predisposing to the need for continued antiparkinsonian treatment could be identified. In an additional double-blind cross-over study of 12 patients presenting persisting neuroleptic-induced parkinsonism, it was found that G 31.406 (a new potentially antiparkinsonian drug), compared with placebo, had an antiparkinsonian effect (P less than 0.01) as well as an antidepressant effect (P less than 0.05). G 31.406 resulted in an improvement in anxiety and schizophrenia-score in some patients. Compared with placebo, orphenadrine had a more questionable effect on parkinsonism (0.05 less than P less than 0.01) and no significant effect on mental symptoms. There were no significant differences between the effects of G 31.406 and orphenadrine.

Effect of anti-parkinsonism drugs on gastric emptying and intestinal transit in the rat

The effect of atropine sulfate, trihexyphenidyl HCl, benztropine mesylate, diphenhydramine HCl and ethopropazine HCl on gastric emptying and intestinal transit of a phenol red solution in the rat was examined. Intraperitoneal administration of 0.3 mg/kg atropine, 1.2 mg/kg benztropine and trihexyphenidyl results in a marked decrease in gastric emptying and intestinal transit rate when compared to controls. Oral administration of these agents produced variable and unpredictable results. Single and multiple oral dose (0.6--3 mg/kg) studies with trihexyphenidyl failed to produce any significant decreases in gastric emptying rates. A single oral dose of benztropine (0.6--3 mg/kg) failed to reduce the gastric emptying rate, but multiple dose studies produced a significant decrease in the gastric emptying rate. Effects on gastric emptying and intestinal transit were seen after single and multiple oral doses of diphenhydramine and ethopropazine.