Pergolide-induced pleuropulmonary fibrosis

Drug-induced retroperitoneal fibrosis: short aetiopathogenetic note, from the past times of ergot-derivatives large use to currently applied bio-pharmacology

Among the secondary forms of retroperitoneal fibrosis (RPF), that drug-induced shows very intriguing aspects given both the broad range of involved pharmaceuticals and the considerable interest arisen from the related pathogenetic mechanisms. The particular incidence, in the last four decades past century, of the RPF due to long-term use of ergot alkaloid derivatives (ergotamine, methysergide, pergolide, bromocriptine, cabergoline) and specific L-dopa derived agents, such as methyldopa, as well as to different analgesics, came progressively down given that their long-term use for either the prevention of migraine attacks or the therapy of chronic pathologies (Parkinson's disease, prolactinoma, pain management, etc) has been, year after year, supplanted or even made unavailable in many countries. More recently, instead, the occurrence of the RPF has been sometimes identified with the use of antitumoral chemotherapeutics, such as carboplatin and methotrexate, and, just lately, as an unusual side-effect of certain biological agents, about which it is timely to go into specific pathogenetic problems in more depth.

Current trends in the management of uremic restless legs syndrome: a systematic review on aspects related to quality of life, cardiovascular mortality and survival

Restless legs syndrome (RLS) affects almost one out of three end-stage renal disease patients. This review assesses the current treatment options for uremic RLS and the potential benefits of those treatments on quality of life parameters, cardiovascular mortality and survival. A systematic review was conducted searching PubMed and Scopus by using the Cochrane and PRISMA guidelines. Fourteen studies met the inclusion criteria in which the international RLS study group criteria were used as the primary diagnostic tool. Both pharmacological and non-pharmacological approaches were found to reduce the severity of uremic RLS symptoms. Only four studies reported changes on aspects related to quality of life while those changes were also associated with health benefits that resulted in reduced cardiovascular risk. The severity of uremic RLS symptoms can be ameliorated by using dopamine agonists and gabapentin, intravenous iron, exercise or supplementation with vitamins C and E, although some of those treatment benefits may be transient. There is a lack of strong evidence regarding the effects of the pharmacological approaches on quality of life and cardiovascular survival and mortality. In contrast exercise has been proven beneficial in both reducing the RLS symptoms' severity score and improving the quality of life.

The serotonergic system in Parkinson's disease

Although the cardinal manifestations of Parkinson's disease (PD) are attributed to a decline in dopamine levels in the striatum, a breadth of non-motor features and treatment-related complications in which the serotonergic system plays a pivotal role are increasingly recognised. Serotonin (5-HT)-mediated neurotransmission is altered in PD and the roles of the different 5-HT receptor subtypes in disease manifestations have been investigated. The aims of this article are to summarise and discuss all published preclinical and clinical studies that have investigated the serotonergic system in PD and related animal models, in order to recapitulate the state of the current knowledge and to identify areas that need further research and understanding.

Cardiac and noncardiac fibrotic reactions caused by ergot-and nonergot-derived dopamine agonists

There is growing evidence that the ergot-derived dopamine agonists cabergoline and pergolide can cause fibrotic cardiac valvulopathy. Data on other fibrotic reactions and nonergot-derived dopamine agonists are sparse. Aim of this study was to investigate whether there are signals that dopamine agonists are related to cardiac and other fibrotic reactions. We identified all reports of fibrotic reactions at the heart, lung, and retroperitoneal space associated with dopamine agonists within the US Adverse Event Reporting System database. Disproportionality analyses were used to calculate adjusted reporting odds ratios (RORs). For ergot-derived dopamine agonists (bromocriptine, cabergoline, pergolide), the RORs of all reactions under study were increased, whereas no such increases were observed for nonergot-derived drugs (apomorphine, pramipexole, ropinirole, rotigotine). Fibrotic reactions due to ergot-derived dopamine agonists may not be limited to heart valves. For nonergot-derived dopamine agonists, no drug safety signals were evident.

Hyper-IgG4 disease: report and characterisation of a new disease

BACKGROUND

We highlight a chronic inflammatory disease we call 'hyper-IgG4 disease', which has many synonyms depending on the organ involved, the country of origin and the year of the report. It is characterized histologically by a lymphoplasmacytic inflammation with IgG4-positive cells and exuberant fibrosis, which leaves dense fibrosis on resolution. A typical example is idiopathic retroperitoneal fibrosis, but the initial report in 2001 was of sclerosing pancreatitis.

METHODS

We report an index case with fever and severe systemic disease. We have also reviewed the histology of 11 further patients with idiopathic retroperitoneal fibrosis for evidence of IgG4-expressing plasma cells, and examined a wide range of other inflammatory conditions and fibrotic diseases as organ-specific controls. We have reviewed the published literature for disease associations with idiopathic, systemic fibrosing conditions and the synonyms: pseudotumour, myofibroblastic tumour, plasma cell granuloma, systemic fibrosis, xanthofibrogranulomatosis, and multifocal fibrosclerosis.

RESULTS

Histology from all 12 patients showed, to varying degrees, fibrosis, intense inflammatory cell infiltration with lymphocytes, plasma cells, scattered neutrophils, and sometimes eosinophilic aggregates, with venulitis and obliterative arteritis. The majority of lymphocytes were T cells that expressed CD8 and CD4, with scattered B-cell-rich small lymphoid follicles. In all cases, there was a significant increase in IgG4-positive plasma cells compared with controls. In two cases, biopsies before and after steroid treatment were available, and only scattered plasma cells were seen after treatment, none of them expressing IgG4. Review of the literature shows that although pathology commonly appears confined to one organ, patients can have systemic symptoms and fever. In the active period, there is an acute phase response with a high serum concentration of IgG, and during this phase, there is a rapid clinical response to glucocorticoid steroid treatment.

CONCLUSION

We believe that hyper-IgG4 disease is an important condition to recognise, as the diagnosis can be readily verified and the outcome with treatment is very good.

Advances in the delivery of treatments for Parkinson's disease

Innovative drug delivery in Parkinson's disease (PD) has the potential to reduce or avoid many side effects of current treatment, such as wearing-off type fluctuations, dyskinesia, on-off phenomena or bouts of motor freezing. The traditional orally administered formulations of l-dihydroxyphenylalanine combined with a peripheral aromatic acid decarboxylase inhibitor remain the mainstay of treatments for PD. However, such combination therapies have been further formulated to extend their duration of action by including a catechol-O-methyltransferase inhibitor. Preventing the breakdown of dopamine has also been achieved by monoamine oxidase-B inhibition; this approach now having been formulated for sublingual use (Zelapar, Valeant Pharmaceuticals). An alternative approach bypasses the oral route of administration and instead relies on continuous duodenal infusion (Duodopa, Solvay, NeoPharma AB) for better therapeutic effect. The clinical use of dopamine agonists as antiparkinsonian drugs now incorporates a variety of delivery techniques. For example, apomorphine, which relies on parenteral administration for maximum bioavailability, may be delivered via rectal, intranasal, sublingual and subcutaneous (e.g., Apokyn, Mylan Bertek) routes. Meanwhile, rotigotine and lisuride have both been formulated for delivery via skin patches. Finally, the authors examine more experimental delivery techniques, including the delivery of genes via viral vectors or liposomes, intracranial transplant of a variety of cells and of L-dihydroxyphenylalanine by prodrug-dispensing liposomes or pulmonary delivery (AIR, Alkermes). The advent and application of these varied technologies will help encourage patient-specific means of treatment for PD.

Ropinirole: use in restless legs syndrome

Ropinirole is a nonergoline dopamine agonist indicated for the treatment of Parkinson’s disease as monotherapy or combination therapy. However, recent studies have demonstrated a role for this drug in the treatment of restless legs syndrome. Dopaminergic agents, such as ropinirole, are considered the first-line treatment for restless legs syndrome. The dosage of ropinirole needed to treat the symptoms of restless legs syndrome appears to be much smaller (0.25–4.0 mg/day) than that necessary for Parkinson’s disease therapy. Ropinirole is generally well tolerated, with no serious adverse effects. The adverse effects of ropinirole are comparable with those of other dopamine agonists, including nausea and dizziness. In contrast to ergoline substances, ropinirole is free from retroperitoneal, pleural, pericardial fibroses and restrictive valvular heart disease. Clinical studies have indicated that ropinirole reduces the motor symptoms of restless legs syndrome effectively and improves sleep quantity and quality.

Pramipexole for the treatment of restless legs syndrome

Restless legs syndrome (RLS) is a common disorder that is estimated to affect 10% of Americans. However, it remains largely undiagnosed and untreated by clinicians. The primary symptoms of this condition are leg discomfort or an urge to move that is temporarily relieved by movement and is worse at rest and at bedtime. RLS impacts the quality of life of the sufferer by disrupting sleep and disturbing or curtailing work and social activities. Approximately 80% of RLS sufferers also have periodic limb movements during sleep, in which repetitive leg movements fragment sleep and may result in daytime drowsiness. RLS may be treated by dopaminergic agents, benzodiazepines, anticonvulsants and opiates; dopamine agonists are currently considered first-line therapy for this condition. Pramipexole has been studied in the treatment of RLS since 1998. This article reviews the role of this medication in the management of this serious neurological disorder.

Valvular heart disease in patients taking pergolide

OBJECTIVE

To Investigate the frequency of valvular heart disease in patients taking pergolide.

PATIENTS AND METHODS

The medical records of patients seen at the Mayo Clinic in Jacksonville, Fla, between 1998 and 2003 were searched electronically for the word pergolide and the presence of a 2-dimensional echocardiogram. Patients who had not taken pergolide before undergoing echocardlography served as the control group. Echocardiograms were reviewed for the presence of valvular regurgitation. The frequency of valvular disease in patients taking pergolide was calculated and compared with controls. Associations with dosage and years of treatment also were examined.

RESULTS

Fifty-five patients made up the pergolide group, and 63 served as controls. When looking at aortic regurgitation (AR) of any degree, 45% of patients in the pergolide group had AR, compared with 21% of controls (P = .006). The frequency of moderate to severe valvular regurgitation in the pergolide group was 11% (95% confidence interval [CI], 4%-22%), 13% (95% CI, 5%-24%), and 13% (95% CI, 5%-24%) for the tricuspid, mitral, and aortic valves, respectively. No statistical difference was identified in the frequency of moderate to severe valvular regurgitation (mitral, tricuspid, or aortic) when compared with controls. There was marginal evidence of an association between a higher daily dosage of pergolide and moderate to severe AR (P = .05).

CONCLUSION

The frequency of AR appears to be Increased in patients taking pergolide. Our study suggests that if a cause-effect relationship exists between pergolide and valvular heart disease, it likely occurs at a low but clinically important Incidence and may be associated with dosage.

Dopamine agonists in Parkinson’s disease

Levodopa (LD), the immediate precursor of dopamine, is the most effective agent in the treatment of Parkinson's disease (PD). While quite successful in treating the primary motor deficits of PD, most patients eventually develop LD-related motor fluctuation, dyskinesias and other adverse effects associated with chronic LD therapy. There is also concern that LD is neurotoxic, although this has not been demonstrated in any in vivo studies. Dopamine agonists (DAs) have been shown to be about as effective as LD in symptomatic treatment of mild-to-moderate PD. In addition, there is a lower tendency to develop motor fluctuations and dyskinesias with DA treatment than after initiation of therapy with LD. Furthermore, there is preclinical and clinical data to suggest a slowing of neurodegeneration with DAs. The adverse effects of DAs are similar to those experienced with LD, except that the ergot agents are associated with a small risk of tissue fibrosis not noted with the non-ergot DAs.

Diagnosis and management of pergolide-induced fibrosis

We report on 2 patients treated with pergolide, 1 of whom developed pleural fibrosis and the other retroperitoneal fibrosis. In both cases, an extensive diagnostic evaluation and surgical intervention were required to reach a diagnosis. Based on our experience with these patients and a review of cases of pergolide-induced fibrosis in the English-language literature, we propose guidelines for the diagnosis and management of this rare complication.