Effect of new dopamine-blocking agent (oxiperomide) on drug-induced dyskinesias in Parkinson's disease and spontaneous dyskinesias.

Oxiperomide, a new dopamine-receptor antagonist, was found to decrease dyskinesias in patients with Parkinson''s disease receiving levodopa or other dopamine agonists without necessarily increasing Parkinsonian symptoms. Oxiperomide also decreased spontaneous dyskinesias in those with tics and chorea and to a less extent in those with torsion dystonia, without necessarily causing Parkinsonism. These results provide evidence that more than one population of dopamine receptors exist in the extra pyramidal system, and encourage the search for selective dopamine antagonists.     

Interaction between Levodopa and Methyldopa

The interaction between methyldopa and levodopa was studied in 18 patients with Parkinsonism. Together they produced a fall in blood pressure in doses which when given alone had no effect or only a slight hypotensive effect. Severe hypotension never occurred. It is reasonable to give methyldopa to hypertensive patients on levodopa but the regimen should be initiated in hospital.     

Levodopa in Huntingtons chorea.

Sixteen patients with Huntington''s chorea were treated for periods as long as 8 months with levodopa. The condition of none of the patients improved; in fact, there appeared to be an exacerbation of chorea and dementia in addition to undesirable behavioural changes. Therefore, future use of levodopa in these patients is not warranted. The postulated association of low homovanillic acid values in cerebrospinal fluid and favourable response to levodopa therapy was not borne out.     

Effect of Age and Arteriosclerosis on the Response of Parkinsonian Patients to Levodopa

Twenty-four patients with Parkinsonism were treated with levodopa for up to one year. Ten were aged under 65, 12 were aged 65 or over, and two were specifically included because they were considered to have arteriosclerotic Parkinsonism. These two patients showed no response to treatment. The 10 younger patients showed less clinical evidence of arteriosclerosis than the older ones, and responded significantly better to treatment with levodopa. Mean improvement was 61% in the younger group after 12 months'' treatment and 28% in the older group. Improvement was greatest within three months of starting treatment. Abnormal movements which resulted from treatment with levodopa could be reduced with only slight loss of therapeutic benefit by the addition of tetrabenazine.     

Comparison of therapeutic effects and mortality data of levodopa and levodopa combined with selegiline in patients with early,mild Parkinson's disease. Parkinson's Disease Research Group of the United Kingdom.

OBJECTIVE: To compare effectiveness of levodopa and levodopa combined with selegiline in treating early, mild Parkinson''s disease. DESIGN: Open, long term, prospective randomised trial. SETTING: 93 hospitals throughout United Kingdom. SUBJECTS: 520 patients with early Parkinson''s disease who were not receiving dopaminergic treatment. INTERVENTIONS: Treatment with levodopa and dopa decarboxylase inhibitor (arm 1) or levodopa and decarboxylase inhibitor in combination with selegiline (arm 2). MAIN OUTCOME MEASURES: Assessments of serial disability, frequency and severity of adverse events, and deaths from all causes. RESULTS: After average of 5-6 years'' follow up, mortality ratio in arm 2 compared with arm 1 was 1.57 (95% confidence interval 1.09 to 2.30), and difference in survival between the two arms was significant (log rank test, P = 0.015). Hazard ratio adjusted for age and sex was 1.49 (1.02 to 2.16), and after adjustment for other baseline factors it increased to 1.57 (1.07 to 2.31). Patients in arm 1 had slightly worse disability scores than those in arm 2, but differences were not significant. Functionally disabling peak dose dyskinesias and on/off fluctuations were more frequent in arm 2 than arm 1. During the trial the dose of levodopa required to produce optimum motor control steadily increased in arm 1 (median daily dose 375 mg at 1 year and 625 mg at 4 years), but median dose in arm 2 did not change (375 mg). CONCLUSIONS: Levodopa in combination with selegiline seemed to confer no clinical benefit over levodopa alone in treating early, mild Parkinson''s disease. Moreover mortality was significantly higher with combination treatment, casting doubts on its chronic use in Parkinson''s disease.     

L-Dopa in Parkinsonism and the Influence of Previous Thalamotomy

A double-blind cross-over trial over 24 weeks (10 weeks on the active remedy, 4 weeks off treatment, and 10 weeks on placebo) of the effect of L-dopa on idiopathic Parkinsonism (paralysis agitans) has shown no difference in the response obtained in patients who had undergone previous stereotaxic ventrolateral thalamotomy and in those who had not. Of the 34 patients (18 men and 16 women) in the trial 18 had been operated on (nine unilateral, nine bilateral operations) and 16 had not. All patients entering the trial were taking anticholinergic drugs in stable dosage and these were continued throughout. The only factor which seemed to limit the response to treatment was pre-existing hypertension. Of 31 patients who completed the 10-week treatment period, 12 showed marked improvement, 15 moderate improvement, and 4 and mild or negligible change. It seems that previous ventrolateral thalamotomy affords some protection against the development of L-dopa-induced involuntary limb movements on the side contralateral to the operation. As found by others, maximum benefit was seen in bradykinesia and rigidity and related features but a significant reduction in tremor was also noted during treatment. Side effects (nausea, hypotension, and involuntary movements) were common but rarely limited the therapeutic response.     

Idiopathic Parkinsonism Treated with an Extracerebral Decarboxylase Inhibitor in Combination with Levodopa

The clinical actions of levodopa in Parkinsonism, given with and without an extracerebral decarboxylase in hibitor, L-alpha-methyldopahydrazine, were compared. Twenty-one patients were investigated in a “double-blind cross-over” study, administering levodopa in maximum tolerated dosage. L-Alpha-methyldopahydrazine failed to augment the overall therapeutic actions of levodopa but it consistently alleviated nausea. It is concluded that L-alpha-methyldopahydrazine will prove useful in the management of some Parkinsonian patients who have difficulty in taking levodopa alone.     

Clinical Problems: Levodopa Therapy of Patients with Parkinsonism and Heart Disease

Forty patients with Parkinsonism and heart disease were studied before and during the administration of levodopa. Patients with increasing angina, myocardial infarction within the previous year, pre-existing severe postural hypotension, or transient cerebral ischaemia were excluded. Thirty-eight patients showed no adverse effects; angina improved in one patient but later worsened; one patient died of myocardial infarction after a severe gastrointestinal haemorrhage. Therapy with levodopa appears to pose little increased hazard to patients with most forms of heart disease. Inpatient monitoring is recommended at the beginning of therapy, and antiarrhythmic agents should be used when required.     

Ovarian hormone-induced short-latency maternal behavior in ovariectomized virgin Long-Evans rats

Two ovarian hormone regimens reported to induce rapid-onset maternal behavior (MB) in maternally naive virgin, ovariectomized Sprague-Dawley (SD) albino rats (R. S. Bridges, 1984, Endocrinology 114, 930-940; A. L. Giordano, 1987, Doctoral Dissertation, Rutgers University, Newark, NJ) were assessed in Long-Evans (LE) hooded rats, a strain which tends to be less maternally responsive in various situations dissociated from parturition. The combination of sufficiently high and long-lasting treatments with estradiol (E, 10-mm Silastic capsule, sc, on Day 1) and progesterone (P, 3 x 30-mm Silastic capsules, Days 3-13) resulted in a mean MB onset latency (after pup presentation on Day 14) of 1.8 days. In contrast, no-hormone or P-only controls had latencies of about 5.5 days. However, the E + P combination was completely ineffective if the E capsule was withdrawn along with the P capsules, unlike the case for SD rats. Also in contrast to the albinos, E alone was ineffective, while E treatment following P withdrawal was only partially effective. The most efficacious regimen, which included a P treatment (injections of 4 mg/day, Days 3-12 or 3-15) known to maintain pregnancy in ovariectomized rats, resulted in mean latencies of less than or equal to 1 day; 39% overall displayed MB rapidly, i.e., retrieval within 15 min of exposure to pups and crouching by 3 hr, and 89% became maternal by the next day. With this regimen, neither duration of 4 mg/day P treatment (10 or 13 days) nor hysterectomy 2 days before testing affected MB latencies. Thus, the essential features of the previously reported ovarian hormone regimens for induction of short-latency MB are efficacious in LE rats, but the hormonal requirements in this strain seem to be more precise. Factors which might contribute to an even higher percentage maternal on the first day of pup exposure are considered.     

MVPP chemotherapy regimen for advanced Hodgkin's disease

During January 1968 to December 1972, 133 patients with advanced Hodgkin''s disease (HD) were admitted to hospital for combination chemotherapy with mustine, vinblastine, procarbazine, and prednisolone (MVPP regimen). Remission rates were 76% among 49 untreated patients and 90% among 42 patients who had relapsed after radiotherapy. The corresponding five-year survival rates were 65% and 86% respectively. Provided the observed yearly mortality (6%) remains unchanged 75% of patients who had previously received no treatment or irradiation and achieved remission are expected to continue in first remission after five years. Forty-two patients had received prior chemotherapy. They had lower remission and five-year survival rates (40% and 33% respectively), and fewer than half of those achieving remission were still in first remission after five years. There were several reasons for the poor prognosis in this group, including advanced-stage disease (stage IVB), age over 40, and achievement of remission.Chemotherapy was administered on an outpatient basis. Haematological toxicity and immediate drug-related side effects were similar to those of other regimens but there was no appreciable neurotoxicity. Most deaths were due to either HD itself or complications of advanced disease. Five malignancies other than HD occurred in patients who had received both single-agent chemotherapy and radiotherapy before MVPP chemotherapy. Two patients developed osteonecrosis of the femoral heads.Combination chemotherapy has a profound effect on the prognosis of advanced HD. The MVPP regimen yields results comparable to those of other regimens but with perhaps less toxicity.     

Parkinson's disease.

In Parkinson''s disease there is degeneration of neurons in the substantia nigra, with consequent depletion of the neurotransmitter dopamine. The triad of tremor, rigidity and bradykinesia is the clinical hallmark. Drugs currently used for palliative therapy fall into three categories: anticholinergic agents, dopamine precursors (levodopa combined with extracerebral decarboxylase inhibitors) and artificial dopamine agonists. It has been argued, on theoretical grounds, that some drugs slow the progress of Parkinson''s disease, although no firm evidence has supported this. Treatment must be individualized, and more than one type of drug can be given concurrently after a careful build-up in dosage. We review the adverse effects of various drugs and consider new developments such as slow-release preparations, selective D-1 and D-2 agonists and transplants of dopaminergic cells into the brain. The treatment of Parkinson''s disease can be demanding, rewarding and sometimes frustrating, but it remains a most challenging exercise in pharmacotherapy.     

Extracellular Concentrations of Dopamine and Metabolites in the Rat Caudate After Oral Administration of a Novel Catechol-O-Methyltransferase Inhibitor Ro 40–7592

The effect of the systemic administration of a novel, orally active, catechol-O-methyltransferase (COMT) inhibitor, Ro 40-7592, on the in vivo extracellular concentrations of dopamine (DA) and its metabolites, dihydroxyphenylacetic acid (DOPAC) and homovanillic acid (HVA), was studied by transcerebral microdialysis in the dorsal caudate of freely moving rats. Ro 40-7592 (at doses of 3.0, 7.5, and 30 mg/kg p.o.) elicited a marked and long-lasting reduction of HVA, and at doses of 7.5 and 30 mg/kg, an increase of DOPAC output, but it failed to increase DA output. The administration of L-beta-3,4-dihydroxyphenylalanine (L-DOPA, 20 and 50 mg/kg p.o.) with a DOPA decarboxylase inhibitor (benserazide) increased both HVA and DOPAC output, but failed to modify significantly extracellular DA concentrations in dialysates; in contrast, combined administration of L-DOPA+benserazide with Ro 40-7592 (30 mg/kg p.o.) resulted in a significant increase in DA output. Ro 40-7592 prevented the L-DOPA-induced increase in HVA output and markedly potentiated the increase in DOPAC output. To investigate to what extent the increase in extracellular DA concentrations was related to an exocitotic release, tetrodotoxin (TTX) sensitivity was tested. Addition of TTX to Ringer, although abolishing DA output in the absence of L-DOPA, partially reduced it in the presence of L-DOPA+Ro 40-7592 and even more so after L-DOPA without the COMT inhibitor. The results of the present study suggest that metabolism through COMT regulates extracellular concentrations of DA formed from exogenously administered L-DOPA but not of endogenous DA.(ABSTRACT TRUNCATED AT 250 WORDS)     

Effects of levodopa therapy in Parkinson's disease II. Measurement of behavioural changes

Forty-seven patients with Parkinson''s disease were evaluated prior to and during levodopa treatment (at five weeks and at six months), to obtain quantitative measures of the effects of the disease and of levodopa on a variety of cognitive and psychomotor functions, by means of psychological tests and special apparatus. Analysis of the findings in relation to a comparable control group shows that before treatment patients had impaired performance of all motor tasks, but no differences in cognitive functioning were found. Most motor functions had improved after five weeks on levodopa and this improvement was maintained at the six-month follow-up, but cognitive functions remained largely unchanged. The relationship between patients'' age, disability, duration of illness and drug tolerance is also discussed in relation to the functions measured.     

Lack of Change in Basal Ganglia Neuropeptide Content Following Subacute 1-Methyl-4-Phenyl-1,2,3,6-Tetrahydropyridine Treatment of the Common Marmoset

Treatment of common marmosets with 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP; 1-4 mg/kg for up to 4 days) caused a profound parkinsonian state. Ten days from the start of MPTP treatment, all animals showed marked motor impairment, consisting of bradykinesia and akinesia, limb rigidity, postural abnormalities, loss of vocalisation and blink reflex, and, on occasions, postural tremor. Measurement of caudate-putamen monoamine content at this time showed a profound loss in 3,4-dihydroxyphenylethylamine, homovanillic acid, and 3,4-dihydroxyphenylacetic acid concentrations. Measurement of neuropeptide concentrations in the caudate-putamen, internal and external segments of the globus pallidus, nucleus accumbens, substantia nigra, frontal cortex, and hippocampus showed met-enkephalin, leu-enkephalin, and cholecystokinin (CCK-8) concentrations to be unaffected by MPTP treatment. There was a small decrease in the substance P content of frontal cortex, but otherwise the content of this neuropeptide was unaltered. Parkinsonism in the marmoset, induced by MPTP treatment 10 days earlier, does not alter neuropeptide concentrations in the manner observed in Parkinson's disease.     

Involuntary movements in patients taking oral contraceptives

Involuntary movements developed in five women taking oral contraceptives. In one, the sudden onset of a unilateral disturbance suggested a cerebral thrombosis; this case is considered to be a further example of the increased risk of cerebrovascular disease associated with oral contraception. The four other patients suffered a relapse of Sydenham''s chorea between one and four months after starting an oral contraceptive regimen. Possibly an underlying vascular mechanism was responsible for these relapses.     

Amantadine-HCl (Symmetrel) in the Management of Parkinson's Disease: A Double-Blind Cross-Over Study

A double-blind cross-over study was carried out in 54 patients with Parkinson''s disease to evaluate the efficacy of amantadine hydrochloride as compared to a lactose placebo in the management of this illness. Amantadine proved to be a useful and safe addition to the armamentarium when given in daily doses of 200 mg. Forty-eight per cent of patients experienced moderate to good results while 31% showed no measurable improvement. The quality of the improvement was inferior to that obtained with levodopa, but the side effects were fewer. The study could not demonstrate a useful synergistic action between the two drugs, nor could the response to amantadine be used to predict that with levodopa. On the other hand, the addition of amantadine was useful in a few instances where optimal therapeutic doses of levodopa could not be given because of side effects. The mechanism of action of amantadine is still conjectural, but there is strong evidence to indicate some interaction with central dopamine metabolism.     

Long-term effects of prey-availability, partnering and temperature on overall egg capsule output of 'New Zealand flatworms', Arthurdendyus triangulates

Arthurdendyus triangulatus is an invasive terrestrial flatworm that preys on earthworms. To assess A. triangulatus egg capsule production, flatworms were maintained in ventilated polypropylene tubs (7.5 L) kept in controlled environment (CE) chambers or outdoors in the ground. Controlled environment chambers were maintained at 8°C or 14°C, flatworms kept singly or paired within tubs and offered Eisenia fetida according to a weight equalling one‐eighth or one‐half of the mean flatworm weight, or left unfed. The tubs were a successful method for keeping flatworms, with some surviving for over one year. The greatest number of egg capsules produced by an individual A. triangulatus was nine over a 16 week period for a flatworm kept at 14°C and fed at the one‐half regime (0.56 egg capsules flatworm^‐1 week^‐1). Although the effects of treatments varied with CE chambers, there was some evidence from flatworms kept outdoors, that feeding affected egg capsule output, with those flatworms fed at the one‐half regime tending to produce more egg capsules (P= 0.057). Flatworms at the one‐eighth regime or that were unfed produced progressively lighter egg capsules and substantially declined in weight themselves. Nevertheless, even unfed flatworms continued to produce egg capsules for 18 weeks. The lightest egg capsule weighed 8 mg, whilst the heaviest was 180 mg. In the CE chambers at 14°C, there was evidence for two different reproductive/survival strategies. Some flatworms produced cumulatively more egg capsules the longer they survived, whereas others lived longer but produced fewer egg capsules. Flatworms kept without a partner still produced egg capsules up to 35 weeks later. Egg capsules contained a mean of 4.14 (CE chambers) or 4.62 (outdoors) juveniles, with a maximum of 11. Overall, juveniles were 45% of the weight of egg capsules, although larger egg capsules had more juveniles, which comprised a greater proportion of the egg capsule. The conversion of earthworm prey to egg capsule production was estimated at 13%.     

Chorea--an unusual manifestation in a woman recovering from myxedema coma

ObjectiveTo report a case of reversible chorea in a woman with myxedema coma.MethodsWe describe the clinical course, imaging findings, and laboratory test results of a patient who initially presented with myxedema coma and then developed reversible chorea upon treatment.ResultsA 33-year-old woman with a known history of primary hypothyroidism presented with a 3-week history of lethargy, progressing to a precipitous decline in consciousness that required intubation. Physical examination revealed concurrent hypothermia and bradycardia. Laboratory investigations demonstrated a thyrotropin concentration greater than 100 mIU/L, a free triiodothyronine concentration of 1.9 pg/mL, and a free thyroxine concentration of 0.24 ng/dL, but no other metabolic abnormalities. She was treated with intravenous levothyroxine therapy on the first 2 days of hospital admission (200 mcg and 250 mcg, respectively). On day 2, she was obeying commands and she was extubated. She began exhibiting choreiform movements. Thyroid function test results revealed a normal free thyroxine concentration (1.10 ng/dL), but an elevated thyrotropin concentration (40.98 mIU/L) and a low free triiodothyronine concentration (1.9 pg/mL). Findings from computed tomography and magnetic resonance imaging of her brain and analysis of cerebrospinal fluid were normal. Her regimen was transitioned to oral levothyroxine, 88 mcg daily, and by day 4, her choreiform movements ceased.ConclusionsNeurologic manifestations of hypothyroidism include psychomotor slowing, memory deficits, and dementia, with myxedema coma at the extreme of this spectrum. Although chorea is a rare manifestation of hyperthyroidism, this is the first report of a patient with acquired, reversible choreiform movement disorder while still being severely hypothyroid and treated with levothyroxine. (Endocr Pract. 2012;18:e43-e48)