Drug-induced Parkinsonism on the rise: Beware of levosulpiride and its combinations with proton pump inhibitors

Fixed drug combination (levosulpiride and rabeprazole)-induced atypical Parkinsonian's disorders with associated anxiety and low-lying depression

We hereby describe a rare case of levosulpiride-induced atypical parkinsonism presenting with sluggish movements, atypical kinetic tremors (tremors with voluntary movement), periorbital tremors, dystonia, difficulty in speech and coordination, postural imbalance, with additional features of difficulty in swallowing and drooling with associated recent onset psychiatric disturbances such as anxiety and low-lying depression. The dechallenge of levosulpiride and medications for associated anxiety and low-lying depression caused a complete remission of the disease within 2 ½ months.

Use of gastrointestinal prokinetics and the risk of parkinsonism: A population-based case-crossover study

BACKGROUND

The disease burden of parkinsonism is extremely costly in the United States. Unlike Parkinson's disease, drug-induced parkinsonism (DIP) is acute and reversible; exploring the causative drug is important to prevent DIP in patients at high-risk of parkinsonism.

OBJECTIVE

To examine whether the use of gastrointestinal (GI) prokinetics is associated with an increased risk of parkinsonism.

METHODS

We conducted a case-crossover study using nationally representative data. We included patients who were newly diagnosed with parkinsonism (ICD-10 G20, G21.1, G25.1) between January 1, 2007 and December 1, 2015. The first prescription date of G20, G21.1, or G25.1 diagnoses was defined as the index date (0 day). Patients with prior extrapyramidal and movement disorders or brain tumors were excluded. We assessed the exposure within the risk (0-29 days) and control periods (60-89 days), before or on the index date. Conditional logistic regression estimated the adjusted odds ratio (aOR) for parkinsonism.

RESULTS

Overall, 2268 and 1674 patients were exposed to GI prokinetics during the risk and control periods, respectively. The use of GI prokinetics significantly increased the occurrence of parkinsonism (aOR = 2.31; 95% Confidence Interval [CI], 2.06-2.59). The use of GI prokinetics was associated with a higher occurrence of parkinsonism in elderly patients (≥65 years old; aOR = 2.69; 95% CI, 2.30-3.14) than in younger patients (aOR = 1.90; 95% CI, 1.59-2.27).

CONCLUSIONS

The use of GI prokinetics was significantly associated with higher occurrences of parkinsonism, necessitating close consideration when using GI prokinetics.

Levosulpiride-Induced Neurological Adverse Effects: A Prospective Study from a Tertiary Care Center

Background

Levosulpiride (LS) is a prokinetic drug increasingly used for the gastric motility disorders. Despite its common use for the gastric motility disorder, the tendency to cause parkinsonism and acute dystonias are under-recognized as the major adverse effects. This study was aimed to evaluate the adverse effects of this drug in patients attending neurology clinics.

Methods

Patients presenting with new-onset extrapyramidal symptoms with respect to LS therapy were selected for the study. A detailed history had been taken using a questionnaire. All the patients were tested for neurological manifestations. The number of cases was then statistically analyzed.

Results

A total of 30 patients were diagnosed with LS-induced movement disorders. The average age of patients was 65 ± 12 years with 17 males and remaining females. Major presentations were tremor, stiffness, dystonia, neck or back pain, dysarthria, and abnormal feelings. Stiffness, tremor, or both were among the most common signs. A statistically significant (P = 0.0154) positive correlation (r = 0.8295) was found between the duration of LS treatment and incidence of tremor/stiffness. Among them, 19 patients were started with dopaminergic drugs and five were given symptomatic measures. Six patients had no follow-up.

Conclusion

The LS treatment was found to produce adverse effects such as tremor and stiffness. Early recognition of this condition is essential for its complete cure and better prognosis. Therefore, one should be cautious about the LS as one of the etiologies for acute recent-onset extrapyramidal syndromes while working up patients.

Modulation of key enzymes linked to Parkinsonism and neurologic disorders by Antiaris africana in rotenone-toxified rats

Background The physiopathologies of many neurologic diseases are characterized by related biochemical dysfunctions that could be explored as drug targets. This study evaluated the effect of a methanol leaf extract of Antiaris africana (MEA) on critical bioindices of Parkinsonism and related neurologic dysfunctions in rats with rotenone-induced neurotoxicity. Methods Animals were administered 50 or 100 mg/kg MEA for 14 consecutive days. Rotenone (1.5 mg/kg) was administered three times per day on days 13 and 14. Coenzyme Q10 (5 mg/kg) was the reference drug. Complex I activity, dopamine level, activities of acetylcholinesterase, myeloperoxidase, Na+/K+ ATPase and glutamine synthetase, as well as oxidative stress indices were evaluated at the end of the period of treatment. Results Rotenone-intoxicated group showed disruption of complex 1 activity, dopamine level, and glutamine synthetase activity with negative alterations to activities of acetylcholinesterase, myeloperoxidase, and Na+/K+ ATPase as well as heightened cerebral oxidative stress. MEA restored brain mitochondria functionality, mitigated altered neurochemical integrity, and ameliorated cerebral oxidative stress occasioned by rotenone neurotoxicity. The activity of A. Africana was comparable with that of 5 mg/kg coenzyme Q10. Conclusions These results indicated that A. africana displayed therapeutic potential against Parkinsonism and related neurologic dysfunctions and support its ethnobotanical use for the treatment of neurologic disorders.

An Unusual Cause of Camptocormia

Background

Camptocormia is defined as forward flexion of the spine that manifests during walking and standing and disappears in recumbent position. The various etiologies include idiopathic Parkinson’s disease, multiple system atrophy, myopathies, degenerative joint disease, and drugs.

Case Report

A 67-year-old diabetic female presented with bradykinesia and camptocormia that started 1 year prior to presentation. Evaluation revealed levosulpiride, a dopamine receptor blocker commonly used for dyspepsia, to be the culprit.

Discussion

It is well known that dopamine receptor blockers cause parkinsonism and tardive syndromes. We report a rare and unusual presentation of camptocormia attributed to this commonly used gastrointestinal drug in the Asian population.

Prokinetics in the Management of Functional Gastrointestinal Disorders

PURPOSE OF REVIEW

The goal of this review is to review the current status of prokinetics and to place it in historical context. Impaired motility and thus propulsion have long been thought to play important roles in the pathogenesis of a number of gastrointestinal disorders including gastroesophageal reflux disease (GERD), gastroparesis, chronic idiopathic pseudo-obstruction, and constipation. Historically, disordered motility was also thought to contribute to a number of functional gastrointestinal disorders such as functional dyspepsia (FD) and irritable bowel syndrome (IBS).

RECENT FINDINGS

As we learn more of the pathophysiology of FD, IBS, GERD, constipation, and gastroparesis, the limitations of a therapeutic strategy based on the stimulation of motility (i.e., the use of a prokinetic) have become apparent and the disappointments of the past explained. The development of prokinetic drugs has also been hampered by the non-selective nature of many of the agents studied to date which resulted in some unexpected side effects. There is still an unmet need for an effective and safe prokinetic, but drug development in this area must be mindful of the challenges of the area and the need for selectivity for a given target receptor.