Parkinsonism and Parkinson's disease associated with long-term administration of sertraline

Sialorrhoea associated with sertraline use

INTRODUCTION

Sialorrhoea, which has been defined as excessive amount of saliva in the mouth, can be a debilitating symptom. Psychoactive drugs may cause an increase or decrease in saliva secretion. Antidepressant drugs, especially tricyclic antidepressants and less often serotonin reuptake inhibitors, are often associated with a decrease in salivation and the complaint of dry mouth.

CASE PRESENTATION

A 46-year-old male patient with complaints of being depressed, lack of motivation, irritability and difficulty in falling asleep was started on sertraline treatment and had trouble with sialorrhoea after the dose increase, without other causes of hypersalivation.

DISCUSSION

We could not find report of any case with antidepressant-associated sialorrhoea in the literature. Future cases may support a relationship between sertraline and sialorrhoea.

Tramadol-induced parkinsonism: a case report of a 75-year-old woman

Adverse drug reaction (ADR) is a form of unwanted reaction and is the crucial reason for illness and death. Tramadol-induced parkinsonism is a kind of ADR that occurs after the repeated intake of tramadol. Long-term exposure to tramadol has been known to induce tremor and alter the functioning of dopamine. This case report introduces a 75-year-old woman diagnosed with tramadol-induced parkinsonism due to the administration of tramadol for the treatment of post-operated (breast cancer) acute onset of severe pain on the left side of the chest. The assessment of the offending drug was carried out via Naranjo probability scale. A score of 6 was reported for this patient, defining tramadol as a probable cause of this reaction. For the management of the drug-induced parkinsonism, levodopa/carbidopa was prescribed and the symptoms related to parkinsonism resolved within a week. The age of the patient and the female gender is considered to be the main risk factor for the occurrence of such reaction. This case report is an attempt to spread awareness about the negative consequences of long-term use of tramadol in old patients. Thus, the medical practitioners must be very careful while administering tramadol to the old aged population.

Drug-induced movement disorders

INTRODUCTION

Drug-induced movement disorders (DIMDs) can be elicited by several kinds of pharmaceutical agents. The major groups of offending drugs include antidepressants, antipsychotics, antiepileptics, antimicrobials, antiarrhythmics, mood stabilisers and gastrointestinal drugs among others.

AREAS COVERED

This paper reviews literature covering each movement disorder induced by commercially available pharmaceuticals. Considering the magnitude of the topic, only the most prominent examples of offending agents were reported in each paragraph paying a special attention to the brief description of the pathomechanism and therapeutic options if available.

EXPERT OPINION

As the treatment of some DIMDs is quite challenging, a preventive approach is preferable. Accordingly, the use of the offending agents should be strictly limited to appropriate indications and they should be applied in as low doses and as short duration as the patient's condition allows. As most of DIMDs are related to an unspecific adverse action of medications in the basal ganglia and the cerebellum, future research should focus on better characterisation of the neurochemical profile of the affected functional systems, in addition to the development of drugs with higher selectivity and better side-effect profile.

Extrapyramidal Reactions Associated with Serotonergic Antidepressants

OBJECTIVE

Extrapyramidal reactions (EPRs) associated with serotonergic antidepressant treatments have been reported since 1958. These reactions can be distressing for patients and complicate treatment. Our objective was to complete a follow-up review of published EPR cases reported for serotonergic antidepressants.

DATA SOURCES

Published cases between January 1998 and May 2015 were collected through a medical literature search. Citation reference lists were also searched manually.

STUDY SELECTION AND DATA EXTRACTION

Identified cases were reviewed for patient age, gender, psychiatric diagnosis, dosage, time to reaction onset, concurrent medications, and EPR description. Cases were excluded when there was not a clear description, if descriptions were not consistent with accepted definitions, or if the written English was poor. We included cases of akathisia, dystonia, dyskinesia, parkinsonism, or mixed EPRs. Authors scored each case using the Naranjo adverse drug reaction probability scale.

DATA SYNTHESIS

We identified 86 published reports involving 91 patients; selective serotonin reuptake inhibitors were implicated in 80.2% of cases. All EPR types were reported: 17 akathisia cases, 18 dyskinesia cases, 27 dystonia cases, 19 parkinsonism cases, and 10 mixed EPR cases. EPRs typically occurred within 30 days of either treatment initiation or dose increase. Age, gender, antidepressant dosing, or concurrent antipsychotic treatment did not appear to broadly contribute to EPR risk. Naranjo scores ranged from 2 to 8.

CONCLUSIONS

Case reports associating serotonergic antidepressants with EPRs continue to be published. Practitioners are advised that monitoring for such is important. Rigorous research efforts are needed to better understand the clinical risk factors for these adverse drug reactions.

Monoamine reuptake inhibitors in Parkinson's disease

The motor manifestations of Parkinson's disease (PD) are secondary to a dopamine deficiency in the striatum. However, the degenerative process in PD is not limited to the dopaminergic system and also affects serotonergic and noradrenergic neurons. Because they can increase monoamine levels throughout the brain, monoamine reuptake inhibitors (MAUIs) represent potential therapeutic agents in PD. However, they are seldom used in clinical practice other than as antidepressants and wake-promoting agents. This review article summarises all of the available literature on use of 50 MAUIs in PD. The compounds are divided according to their relative potency for each of the monoamine transporters. Despite wide discrepancy in the methodology of the studies reviewed, the following conclusions can be drawn: (1) selective serotonin transporter (SERT), selective noradrenaline transporter (NET), and dual SERT/NET inhibitors are effective against PD depression; (2) selective dopamine transporter (DAT) and dual DAT/NET inhibitors exert an anti-Parkinsonian effect when administered as monotherapy but do not enhance the anti-Parkinsonian actions of L-3,4-dihydroxyphenylalanine (L-DOPA); (3) dual DAT/SERT inhibitors might enhance the anti-Parkinsonian actions of L-DOPA without worsening dyskinesia; (4) triple DAT/NET/SERT inhibitors might exert an anti-Parkinsonian action as monotherapy and might enhance the anti-Parkinsonian effects of L-DOPA, though at the expense of worsening dyskinesia.

A Case of SSRI Induced Irreversible Parkinsonism

Serotonin specific reuptake inhibitors (SSRI) are widely used antidepressants for variety of clinical conditions and have found popularity. They are sometimes associated with extrapyramidal side effects including Parkinsonism. We report a case of generalized anxiety disorder on treatment with SSRI (fluoxetine / sertraline) who developed irreversible Parkinsonism. SSRI are known to cause reversible or irreversible motor disturbances through pathophysiological changes in basal ganglion motor system by altering the dopamine receptors postsynaptically. Clinician should keep risk benefit ratio in mind and change of antidepressant of different class may be considered. Case is reported to alert physicians to possibility of motor system damage while treating with SSRI.

Drug-induced parkinsonism

INTRODUCTION

Drug-induced parkinsonism (DIP) is the second most common cause of parkinsonism after idiopathic Parkinson's disease (iPD). Initially reported as a complication of antipsychotics, it was later recognized as a common complication of antidepressants, calcium channel antagonists, gastrointestinal prokinetics, antiepileptic drugs and many other compounds. Despite being a major health problem in certain populations, it seems to be frequently overlooked by the medical community.

AREAS COVERED

This paper approaches the concept of DIP, reviews its epidemiology, clinical features and ancillary tests recommended for a correct diagnosis. The authors discuss the different drugs and its pathogenic mechanisms. The relevance of an early recognition and recommendations for a correct management are commented.

EXPERT OPINION

Prescribers need to remain vigilant for DIP, particularly in the elderly, patients taking multiple drugs and those with genetic risk factors involved in iPD. Cessation of the causing agent is the main treatment and there is no evidence of benefit for the use of anticholinergics or levodopa. If the medication cannot be withdrawn, it should be switched to agents with a lower risk of DIP.

Comparative features of the epidemiology of multiple sclerosis and Parkinson's disease: Environmental factors of potential etiological importance

Multiple sclerosis (MS) and Parkinson's disease (PD) are diseases of unknown cause. The etiology of MS is usually considered to be due to a number of potential biological agents while the etiology of PD is usually associated with toxic agents. Despite these differences, both pathologies have strong epidemiological similarities. A comparative analysis is performed of the epidemiology of MS and PD. Potential causal factors for PD may include dopamine-like pharmacological agents. It is proposed that potential causal agents such as certain drugs plus certain vaccines could explain rationally the epidemiology of MS. Ecology and genetics could not be the appropriate lines of research in the etiology of MS/PD because they are supported only in part by the epidemiology.

Endogenous serotonin excites striatal cholinergic interneurons via the activation of 5-HT 2C, 5-HT6, and 5-HT7 serotonin receptors: implications for extrapyramidal side effects of serotonin reuptake inhibitors

The striatum is richly innervated by serotonergic afferents from the raphe nucleus. We explored the effects of this input on striatal cholinergic interneurons from rat brain slices, by means of both conventional intracellular and whole-cell patch-clamp recordings. Bath-applied serotonin (5-HT, 3-300 microM), induced a dose-dependent membrane depolarization and increased the rate of spiking. This effect was mimicked by the 5-HT reuptake blockers citalopram and fluvoxamine. In voltage-clamped neurons, 5-HT induced an inward current, whose reversal potential was close to the K(+) equilibrium potential. Accordingly, the involvement of K(+) channels was confirmed either by increasing extracellular K(+) concentration and by blockade of K(+) channels with barium. Single-cell reverse transcriptase-polymerase chain reaction (RT-PCR) profiling demonstrated the presence of 5-HT2C, 5-HT6, and 5-HT7 receptor mRNAs in identified cholinergic interneurons. The depolarization/inward current induced by 5-HT was partially mimicked by the 5-HT2 receptor agonist 2,5-dimethoxy-4-iodoamphetamine and antagonized by both ketanserin and the selective 5-HT2C antagonist RS102221, whereas the selective 5-HT3 and 5-HT4 receptor antagonists tropisetron and RS23597-190 had no effect. The depolarizing response to 5-HT was also reduced by the selective 5-HT6 and 5-HT7 receptor antagonists SB258585 and SB269970, respectively, and mimicked by the 5-HT7 agonist, 5-CT. Accordingly, activation of either 5-HT6 or 5-HT7 receptor induced an inward current. The 5-HT response was attenuated by U73122, blocker of phospholipase C, and by SQ22,536, an inhibitor of adenylyl cyclase. These results suggest that 5-HT released by serotonergic fibers originating in the raphe nuclei has a potent excitatory effect on striatal cholinergic interneurons.

Drug-induced parkinsonism in the elderly

Drug-induced parkinsonism is primarily caused by drugs that interfere with dopamine stimulation. Antipsychotic drugs are the most common offenders, but drug-induced parkinsonism may be seen with many other drugs, such as antiemetics and certain calcium-channel blockers. These medications are widely used in the elderly. Unlike the first generation of antipsychotic drugs, all of which cause parkinsonism and other extrapyramidal side effects, atypical antipsychotics have motor side effects that are not uniform. Among the atypicals, only quetiapine and clozapine are not associated with drug-induced parkinsonism. Since drug-induced parkinsonism is frequently under-recognized, it may be devastating in an elderly person with already compromised gait.

Drug-induced parkinsonism

Drug-induced parkinsonism (DIP) is the second cause of akinetic rigid syndrome in the Western world and its prevalence is increasing and approaching that of idiopathic Parkinson's disease due to the ageing of the population and to the rising of polypharmacotherapy. DIP was initially reported as a complication of neuroleptics in psychiatric patients, but it has also been described with a great diversity of compounds such as antiemetics, drugs used for the treatment of vertigo, antidepressants, calcium channel antagonists, antiarrythmics, antiepileptics, cholinomimetics and other drugs. Although traditionally considered reversible, DIP may persist after drug withdrawal. At least 10% of patients with DIP develop persistent and progressive parkinsonism in spite of the discontinuation of the causative drug. Irreversible or progressive DIP has been considered as an indication of presymptomatic parkinsonian deficit, unmasked but not caused by the offending drug, but it could be explained by persistent toxicity of the responsible pharmacological agents on the nigrostriatal dopamine pathway. The best treatment of DIP is prevention, including the avoidance of prescription of causative drugs whenever it is not strictly necessary. In patients who require potentially risky medication, it is necessary to perform adequate monitoring for early parkinsonian deficits and early discontinuation if these deficits appear. Atypical neuroleptics are associated with lower risk than first generation antipsychotic drugs. Special precautions are needed in elderly subjects, in patients treated with multiple drugs for prolonged periods of time and in those with familial risk factors including familial parkinsonism or tremor, or in those with genetic variants of genes involved in idiopathic Parkinson's disease.

A placebo-controlled screening trial of tiagabine, sertraline and donepezil as cocaine dependence treatments

AIMS

To conduct a preliminary evaluation of the safety and efficacy of tiagabine, sertraline or donepezil versus an unmatched placebo control as a treatment for cocaine dependence.

DESIGN

A 10-week out-patient study was conducted using the Cocaine Rapid Efficacy and Safety Trial (CREST) study design.

SETTING

This study was conducted at the Cincinnati Medication Development Research Unit (MDRU) and at an affiliated site in Dayton, Ohio.

PARTICIPANTS

Participants met Diagnostic and Statistical Manual version IV (DSM-IV) criteria for cocaine dependence. Sixty-seven participants were enrolled with 55 completing final study measures.

INTERVENTION

The targeted daily doses of medication were tiagabine 20 mg, sertraline 100 mg and donepezil 10 mg. All participants received 1 hour of manualized individual cognitive behavioral therapy on a weekly basis.

MEASUREMENTS

Primary outcome measures of efficacy included urine benzoylecgonine (BE) level, Cocaine Clinical Global Impression Scale-Observer and self-report of cocaine use. Safety measures included adverse events, ECGs, vital signs and laboratory tests.

FINDINGS

Subjective measures of cocaine dependence indicated significant improvement for all study groups. Generalized estimating equations analysis indicated that the tiagabine group showed a trend toward a significant decrease in urine BE level from baseline to weeks 5-8 (P = 0.10) and non-significant changes for the other study groups. No pattern of physical or laboratory abnormalities attributable to treatment with any of the medications was identified. There were three serious adverse events reported, none of which were related to study procedures.

CONCLUSIONS

The present findings suggest that tiagabine may be worthy of further study as a cocaine dependence treatment.

Goals in symptomatic pharmacologic management of frontotemporal lobar degeneration

This review ofpharmacotherapyforfrontotemporal lobar degeneration describes the chemical rationale for agents used and reports observed responses to psychotropic medications. Paroxetine addressed anxiety and repetitive, ritualistic behaviors. Depression was resistant to treatment. Valproic acid and quetiapine calmed agitated subjects without exacerbating Parkinsonism. Donepezil has not emerged as a beneficial medication for this group of subjects. Behavioral disturbances can be alleviatedpharmacologically, but further research might determine guidelines for management of this non-Alzheimer's dementia syndrome that could decrease the frequency of adverse drug events.

Depression in Parkinson's disease

Depression is common in Parkinson's disease (PD), and its identification and treatment are critically important in disease management. Despite depression's high prevalence and major impact on patient quality of life, questions remain regarding its epidemiology and preferred treatment. The authors of this paper summarize available information on the epidemiology of depression in PD, review treatment options, and discuss possible interactions between antidepressants and other agents. This information may help guide clinical treatment and define the need for further studies.