Selegiline in the treatment of Parkinson's disease: its impact on orthostatic hypotension

Inhibitors of MAO-B and COMT: their effects on brain dopamine levels and uses in Parkinson's disease

MAO-B and COMT are both enzymes involved in dopamine breakdown and metabolism. Inhibitors of these enzymes are used in the treatment of Parkinson's disease. This review article describes the scientific background to the localization and function of the enzymes, the physiological changes resulting from their inhibition, and the basic and clinical pharmacology of the various inhibitors and their role in treatment of Parkinson's disease.

Target Selection Recommendations Based on Impact of Deep Brain Stimulation Surgeries on Nonmotor Symptoms of Parkinson's Disease

OBJECTIVE

This review examines the evidence that deep brain stimulation (DBS) has extensive impact on nonmotor symptoms (NMSs) of patients with Parkinson's disease (PD).

DATA SOURCES

We retrieved information from the PubMed database up to September, 2015, using various search terms and their combinations including PD, NMSs, DBS, globus pallidus internus (GPi), subthalamic nucleus (STN), and ventral intermediate thalamic nucleus.

STUDY SELECTION

We included data from peer-reviewed journals on impacts of DBS on neuropsychological profiles, sensory function, autonomic symptoms, weight changes, and sleep disturbances. For psychological symptoms and cognitive impairment, we tried to use more reliable proofs: Random, control, multicenter, large sample sizes, and long period follow-up clinical studies. We categorized the NMSs into four groups: those that would improve definitively following DBS; those that are not significantly affected by DBS; those that remain controversial on their surgical benefit; and those that can be worsened by DBS.

RESULTS

In general, it seems to be an overall beneficial effect of DBS on NMSs, such as sensory, sleep, gastrointestinal, sweating, cardiovascular, odor, urological symptoms, and sexual dysfunction, GPi-DBS may produce similar results; Both STN and Gpi-DBS are safe with regard to cognition and psychology over long-term follow-up, though verbal fluency decline is related to DBS; The impact of DBS on behavioral addictions and dysphagia is still uncertain.

CONCLUSIONS

As the motor effects of STN-DBS and GPi-DBS are similar, NMSs may determine the target choice in surgery of future patients.

Comparison of two methods for selegiline determination: A flow-injection chemiluminescence method using cadmium sulfide quantum dots and corona discharge ion mobility spectrometry

Two analytical approaches including chemiluminescence (CL) and corona discharge ionization ion mobility spectrometry (CD-IMS) were developed for sensitive determination of selegiline (SG). We found that the CL intensity of the KMnO4-Na2S2O3 CL system was significantly enhanced in the presence of L-cysteine capped CdS quantum dots (QDs). A possible CL mechanism for this CL reaction is proposed. In the presence of SG, the enhanced CL system was inhibited. Based on this inhibition, a simple and sensitive flow-injection CL method was proposed for the determination of SG. Under optimum experimental conditions, the decreased CL intensity was proportional to SG concentration in the range of 0.01 to 30.0 mg L(-1). The detection limit (3σ) was 0.004 mg L(-1). Also, SG was determined using CD-IMS, and under optimum conditions of CD-IMS, calibration curves were linear in the range of 0.15 to 42.0 mg L(-1), with a detection limit (3σ) of 0.03 mg L(-1). The precision of the two methods was calculated by analyzing samples containing 5.0 mg L(-1) of SG (n=11). The relative standard deviations (RSDs%) of the flow-injection CL and CD-IMS methods are 2.17% and 3.83%, respectively. The proposed CL system exhibits a higher sensitivity and precision than the CD-IMS method for the determination of SG.

The management of orthostatic hypotension in Parkinson's disease

Orthostatic hypotension (OH) is a common and disabling symptom affecting Parkinson's disease (PD) patients. We present the effect of the different therapies commonly used to manage PD on this clinical manifestation. For this purpose, we describe the relationship between OH and the current treatments employed in PD, such as L-DOPA, dopaminergic agonists, and continuous dopaminergic stimulation therapies. Additionally, we review the therapeutic measures that could be used to ameliorate OH. There are different approaches to deal with this manifestation, including pharmacological and non-pharmacological treatments, although none of them is specifically aimed for treating OH in PD.

Nonmotor outcomes in Parkinson's disease: is deep brain stimulation better than dopamine replacement therapy?

Nonmotor symptoms are an integral part of Parkinson's disease and cause significant morbidity. Pharmacological therapy helps alleviate the disease but produces nonmotor manifestations. While deep brain stimulation (DBS) has emerged as the treatment of choice for motor dysfunction, the effect on nonmotor symptoms is not well known. Compared with pharmacological therapy, bilateral subthalamic nucleus (STN)-DBS or globus pallidum interna (GPi)-DBS has significant beneficial effects on pain, sleep, gastrointestinal and urological symptoms. STN-DBS is associated with a mild worsening in verbal fluency while GPi-DBS has no effect on cognition. STN-DBS may improve cardiovascular autonomic disturbances by reducing the dose of dopaminergic drugs. Because the motor effects of STN-DBS and GPi-DBS appear to be similar, nonmotor symptoms may determine the target choice in surgery of future patients.

[Central autonomic failures]

Autonomic nervous system (ANS) modulates the function of all body organs through both parasympathetic and sympathetic fibers. Orthostatic hypotension is frequently observed in the course of central nervous system diseases including cortical (stroke, epilepsy, dementias), neurodegenerative (Parkinson's disease, multisystem atrophies) and spinal cord diseases. In some cases, the mechanism of orthostatic hypotension associated with central nervous system diseases involves a dysfunction of peripheral ANS fibers.

Neurocardiology: therapeutic implications for cardiovascular disease

The term "neurocardiology" refers to physiologic and pathophysiological interplays of the nervous and cardiovascular systems. This selective review provides an update about cardiovascular therapeutic implications of neurocardiology, with emphasis on disorders involving primary or secondary abnormalities of catecholamine systems. Concepts of scientific integrative medicine help understand these disorders. Scientific integrative medicine is not a treatment method or discipline but a way of thinking that applies systems concepts to acute and chronic disorders of regulation. Some of these concepts include stability by negative feedback regulation, multiple effectors, effector sharing, instability by positive feedback loops, allostasis, and allostatic load. Scientific integrative medicine builds on systems biology but is also distinct in several ways. A large variety of drugs and non-drug treatments are now available or under study for neurocardiologic disorders in which catecholamine systems are hyperfunctional or hypofunctional. The future of therapeutics in neurocardiology is not so much in new curative drugs as in applying scientific integrative medical ideas that take into account concurrent chronic degenerative disorders and interactions of multiple drug and non-drug treatments with each other and with those disorders.

Cardiovascular baroreceptor activity and selective inhibition of monoamine oxidase

Cardiovascular baroreceptor responsiveness of conscious rats treated with selective inhibitors of monoamine oxidase (MAO) types A and B was determined by measurement of blood pressure (BP) and heart rate (HR) responses to intravenous injection of phenylephrine and sodium nitroprusside. Treatment with selegiline (1 or 5 mg/kg p.o. daily for 7 days) did not significantly modify resting levels of BP and HR, lower or upper HR plateau levels, or HR/BP gain. Treatment with clorgyline (2 mg/kg p.o. daily for 7 days) increased HR/BP gain but also did not modify resting BP or HR, or lower and upper plateau levels of HR. The results are compatible with an effect of MAO-A inhibition to modify monoamine levels in medullary areas participating in CNS control of blood pressure.

Selegiline and blood pressure in patients with Parkinson's disease

OBJECTIVES

Parkinson's disease (PD) frequently affects both the extrapyramidal system and the autonomic nervous system (ANS), the latter also being sometimes disturbed by PD medications. Specifically selegiline is known to disturb cardiovascular ANS functions and may cause or enhance orthostatic hypotension.

METHODS

In order to study the effect of the withdrawal of selegiline on the regulation of blood pressure (BP) in advanced PD, an orthostatic test was performed in 14 PD patients with wearing-off before the morning levodopa dose and thereafter repetitively at 1-h intervals for up to 4 h. A Unified Parkinson's Disease Rating Scale motor score evaluation was also carried out hourly. The tests were repeated after a 4-week selegiline washout period.

RESULTS

Selegiline withdrawal decreased systolic BP significantly during the on-stage in a supine position as well as during the orthostatic test. The initial drop of BP in the orthostatic test was significantly smaller after selegiline withdrawal. The heart rate remained unaffected.

Orthostatic hypotension as an early finding in Parkinson's disease

Patients with Parkinson's disease (PD) commonly have clinically significant orthostatic hypotension (OH). In such patients PD+OH might be confused with multiple system atrophy (MSA), in which OH is a frequent finding, or with pure autonomic failure (PAF), if OH preceded clinical manifestations of the movement disorder. This study addressed whether OH can occur as an early finding in PD+OH. Historical data were analyzed from 35 patients with PD+OH evaluated at the NIH. OH was considered early if the patient had OH before, concurrent with, or starting within 1 year after onset of a symptomatic movement disorder. MSA was excluded by myocardial 6-[(18)F]fluorodopamine-derived radioactivity more than 2 standard deviations below the normal mean. Among the 35 PD+OH patients, 21 (60 %) had documentation of OH as an early finding. In 4 such patients, OH had preceded parkinsonism, and in 4 others, OH had dominated the early clinical picture, even after cessation of levodopa treatment for the movement disorder. In PD, OH can occur early in the disease, occasionally preceding or overshadowing the movement disorder.

Cardiovascular dysautonomia as a cause of falls in Parkinson's disease

Parkinson's disease (PD) patients have a ninefold increased risk of recurring falls compared to healthy controls. The risk of falling due to cardiovascular dysautonomia (CVD) is not quantifiable. But, CVD is an integral part of the disease and at least 20% of PD patients suffer from orthostatic hypotension, an expression of CVD. One way to reduce falls due to CVD in PD patients could be to give adequate information on the relationship between falling risks and cardiovascular dysautonomia to patients and their caregivers. Moreover, drugs given for PD might contribute to OH and we propose that education and non-pharmacological strategies for its treatment might be preferable, especially because of the low efficacy of drugs available for the treatment of OH and the frailty of elderly PD patients.