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Cardiovascular Autonomic Dysfunction in Patients with Drug-Induced Parkinsonism

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Cardiovascular Autonomic Dysfunction in Patients with Drug-Induced Parkinsonism JCN Open Access ORIGINAL ARTICLE pISSN 1738-6586 / eISSN 2005-5013 / J Clin Neurol 2016 Cardiovascular Autonomic Dysfunction in Patients with Drug-Induced Parkinsonism Joong-Seok Kima Background and PurposezzRecent studies have shown that several nonmotor symptoms Dong-Woo Ryua a differ between Parkinson’s disease (PD) and drug-induced parkinsonism (DIP). However, Ju-Hee Oh there have been no reports on cardiovascular autonomic function in DIP, and so this study a Yang-Hyun Lee investigated whether cardiovascular autonomic function differs between PD and DIP pa- Sung-Jin Parka tients. a Kipyung Jeon MethodszzThis study consecutively enrolled 20 DIP patients, 99 drug-naïve PD patients, Jong-Yun Leea and 25 age-matched healthy controls who underwent head-up tilt-table testing and 24-h am- Seong Hee Hoa bulatory blood pressure monitoring. Jungmin Soa ResultszzOrthostatic hypotension was more frequent in patients with PD or DIP than in b healthy controls. In DIP, orthostatic hypotension was associated with the underlying psychi- Jin Hee Im a atric diseases and neuroleptics use, whereas prokinetics were not related to orthostatic hypo- Kwang-Soo Lee tension. The supine blood pressure, nighttime blood pressure, and nocturnal blood pressure aDepartment of Neurology, dipping did not differ significantly between the DIP and control groups. Supine hypertension College of Medicine, The Catholic and nocturnal hypertension were more frequent in PD patients than in controls. University of Korea, Seoul, Korea bDepartment of Neurology, Inje University ConclusionszzThe included DIP patients frequently exhibited orthostatic hypotension that Sanggye Paik Hospital, Seoul, Korea was associated with the underlying diseases as well as the nature of and exposure time to the of- fending drugs. Clinicians should individualize the manifestations of DIP according to underlying diseases as well as the action mechanism of and exposure time to each offending drug. Key Wordszz Parkinson’s disease, drug-induced parkinsonism, cardiovascular autonomic dysfunction. INTRODUCTION Drug-induced parkinsonism (DIP) is the second most common cause of parkinsonism in the elderly after Parkinson’s disease (PD).1 DIP is traditionally associated with old-genera- tion (typical) antipsychotic agents, though it can also occur during the administration of several other classes of drugs including the newer (atypical) antipsychotic agents, gastroin- testinal prokinetics, and calcium-channel-blocking agents.2-4 The clinical presentations of DIP and PD are very similar, and therefore patients with Received March 28, 2016 1 Revised May 7, 2016 DIP are frequently misdiagnosed as having PD. Although most DIP patients experience a Accepted May 10, 2016 full and long-lasting recovery from DIP with no subsequent PD after discontinuing the of- Correspondence fending drugs, some patients develop persistent and worsening parkinsonian symptoms af- Joong-Seok Kim, MD, PhD ter drug discontinuation (i.e., subclinical parkinsonism or DIP unmasks PD) or experience Department of Neurology, the reappearance of PD after full remission from DIP (i.e., DIP antedates PD).5 Seoul St. Mary’s Hospital, College of Medicine, Cardiovascular autonomic dysfunction is relatively common in patients with PD, and can The Catholic University of Korea, occur independently of levodopa treatment and early in the course of the disease.6 The 222 Banpo-daero, Seocho-gu, Seoul 06591, Korea manifestations of this dysfunction include orthostatic hypotension (OH), supine hyperten- Tel +82-2-2258-6078 cc This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Com- Fax +82-2-599-9686 mercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial E-mail [email protected] use, distribution, and reproduction in any medium, provided the original work is properly cited. Copyright © 2016 Korean Neurological Association 1 JCN Autonomic Dysfunction in DIP sion (SH), nocturnal hypertension (NH), and absence of a de- tients were evaluated using the Unified Parkinson’s Disease crease in blood pressure (BP) during the night (nondipping).6,7 Rating Scale (UPDRS) Parts 1–3 and classified according to Recent analyses utilizing a nonmotor symptom question- the modified Hoehn and Yahr (H&Y) stage. Patients with the naire found that several nonmotor symptoms such as urinary following characteristics were excluded from the study: 1) and sleep symptoms and disturbances of taste or smell auto- history of diabetic neuropathy or other peripheral/autonom- nomic dysfunction occurred more frequent in patients with ic neuropathy, 2) history of previous relevant cardiac disease, PD than in those with DIP.8,9 However, cardiovascular auto- or any abnormalities on routine chest radiography or elec- nomic function has not previously been assessed in patients trocardiography, and 3) taking medications known to influ- with DIP. ence cardiovascular autonomic function. In this study we evaluated the cardiovascular autonomic Suspected offending drugs were continued in DIP patients function during head-up tilt-table testing and performed during all of the tests. Antihypertensive medications were 24-h ambulatory BP monitoring in PD and DIP patients as discontinued 7 days before the BP tests in all subjects, and no well as control subjects. serious clinical problems were observed during this period. METHODS Tilt-table testing The patients were examined in a temperature-controlled clini- Patients cal investigation room after having fasted overnight (except for This study was approved by the Institutional Review Board water). Electrocardiographic and noninvasive continuous-BP- of Seoul St. Mary’s Hospital, and each subject provided writ- monitoring leads were connected (YM6000, Mediana Tech, ten informed consent to participate. Twenty patients with Redmond, WA, USA). After 30 minutes of supine resting, DIP were enrolled consecutively, in addition to 99 with PD head-up tilt-table testing (20 minutes at 60°) was performed who met the clinical diagnostic criteria of the UK Brain Bank using a Manumed Special Tilt1-section tilt-table (ENRAF between March 2014 and February 2015.10 A clinical diagno- NONIUS, Rotterdam, the Netherlands). The BP was mea- sis of DIP was made based on the following diagnostic crite- sured manually every 5 minutes before tilting, at 1, 3, 5, 10, 15, ria:4 1) presence of at least two of the four cardinal signs and 20 minutes during head-up tilting, at 1 minute after tilt- (tremor, rigidity, bradykinesia, and impaired postural reflex- ing, and as deemed necessary to ensure subject safety. The es), 2) absence of a personal history of extrapyramidal disor- mean supine baseline and lowest tilt values for BP were re- ders before receiving treatment with an offending drug, 3) on- corded. Statistical analysis was applied to the lower values set of symptoms during the course of treatment with an from 3 and 5 minutes. offending drug, 4) reversal of parkinsonian symptoms (though OH was defined as a decrease in the systolic blood pres- not necessarily completely) after discontinuing offending sure (SBP) of at least 20 mm Hg or in the diastolic blood pres- drugs during a follow-up lasting more than 6 months, and 5) sure (DBP) of at least 10 mm Hg between 2 and 5 minutes normal dopamine transporter positron-emission tomography after the initiation of a head-up tilt.22,23 Patients with SBP ≥140 scan using 18F-N-(3-fluoropropyl)-2beta-carbon ethoxy-3be- mm Hg or DBP ≥90 mm Hg were considered to have SH.24-26 ta-(4-iodophenyl) nortropane (FP-CIT). All of the PD pa- tients exhibited a decreased uptake of FP-CIT in the basal Ambulatory blood pressure monitoring ganglia. An automated 24-h BP recording instrument (Mobil-O- The DIP patients were subgrouped according to their un- Graph NG, I.E.M., Stolberg, Germany) was used to measure derlying diseases (psychiatric diseases vs. functional dyspep- the ambulatory BP every 15 minutes during the day and ev- sia or gastrointestinal prophylaxis) since patients with a psy- ery 30 minutes during the night. The mean values of SBP, chiatric disease may experience some degree of autonomic DBP, and heart rate during the daytime, nighttime, and over dysfunction and most neuroleptics have the side effect of OH 24-h periods were evaluated. Nocturnal decreases in BP and and act on dopaminergic, noradrenergic, cholinergic, and heart rate were calculated as percentage changes between the serotonergic pathways,11-18 whereas most prokinetics mainly daytime and nighttime mean values. Subjects with a <10% inhibit the dopamine D2 receptor in the central nervous sys- nocturnal decrease in mean BP were considered nondip- tem.19-21 Twenty-five age-matched healthy subjects free from pers.27 NH was defined according to the 2013 European Hy- neurological disease were enrolled as controls. pertension Society/European Cardiology Society guidelines Clinical information was collected, including age, sex, (i.e., mean nighttime SBP/DBP ≥120/70 mm Hg).28 symptom duration, history of arterial hypertension, diabetes mellitus, cigarette smoking, and current medications. All pa- 2 J Clin Neurol 2016 Kim JS et al. JCN Data analysis therapeutic range of pharmaceutical introduction in all DIP Statistical analyses were performed using SPSS (version 15.0 patients. for Windows, SPSS Incorporated, Chicago, IL, USA). One- PD and DIP patients frequently had OH (controls vs. PD way analysis of variance was used to compare means between vs. DIP, 4.0% vs. 27.1% vs. 25.0%; χ2=6.236, p=0.016). The groups, and Pearson’s χ2 test was used to compare the fre- orthostatic change in SBP (ΔSBP) was also greater in the PD quencies of categorical variables. The Mann-Whitney non- and DIP groups than in the control group. SH and NH were parametric U test was also used to analyze DIP subgroups. more frequent in PD patients than in controls. Supine BP Given the potential influence of age, sex, hypertension, and was higher in patients with PD than in controls and patients diabetes on the results of group comparisons, such compari- with DIP (Table 2).
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