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Today's Drugs BRITISH MEDICAL JOURNAL 24 APRIL 1971 213 Gout Polyarteritis nodosa Neuropathic: Hydrallazine syndrome (procaine Haemochromatosis Takayasu's (pulseless) disease Carpal tunnel median nerve amide, oral contraceptives, etc.) Lipoidosis Wegener's granulomatosis compression Anticoagulant therapy Multicentric Reticulohistocytosis Charcot's joints, tabetic or Isoniazid shoulder-hand syndrome (Lipoid Dermatoarthritis) Neoplastic; Arthropathies associated syringomyelic Serum sickness Myositis ossificans with benign and malignant tumours: Diabetic arthropathy (neuropathic Br Med J: first published as 10.1136/bmj.2.5755.213 on 24 April 1971. Downloaded from Ochronosis Chondrosarcoma and infective) Miscellaneous: Osteomalacia Haemangioma Osborne's syndrome (ulnar nerve Acro-osteolysis syndrome Osteoporosis Left atrial myxoma compression and other compression Degos' syndrome Renal transplant syndrome Metastatic malignant disease neuropathies) Dupuytren's contracture Xanthomatosis (primary Multiple myelomatosis Paraplegia syndrome Knuckle pads (Hale White's syndrome) hypercholesterolaemia) Osteoid osteoma Shoulder-hand syndrome Paget's disease of bone Paget sarcoma Periostitis deformans (Soriano) Vascular: Pseudohypertrophic pulmonary Therapeutic: Septic focus syndrome Avascular necrosis (fat, caisson, etc.) osteoarthropathy Alcoholism Xyphoid syndrome Giant-cell arteritis Synovioma Corticosteroid arthropathy Today's Drugs With the help of expert contributors we print in this section notes on drugs in current use Treatment of Myasthenia-II Severe weakness leading to paralysis may result from either A myasthenic crisis can usually be corrected by administra- a deficiency (myasthenic crisis) or an excess (cholinergic tion of an anticholinesterase. A dose of 0 5 mg neostigmine crisis) of acetylcholine at the neuromuscular junction. The may be given by subcutaneous or intramuscular injection, differential diagnosis between these two conditions is often repeating this every 20 minutes with frequent edrophonium difficult, and the results of giving 10 mg edrophonium intra- tests. As previously mentioned, atropine (0.3-0.6 mg) should venously may provide crucial information. This drug produces be administered to control the muscarinic effects of parenteral improvement in a myasthenic crisis but not in a cholinergic neostigmine. crisis-which may, indeed, become slightly worse. Neverthe- less, the drug has such a short duration of action that for a patient in cholinergic crisis any deterioration due to increased Cholinergic Crisis anticholinesterase activity is unlikely to have serious conse- quences. Like the myasthenic crisis, the cholinergic crisis is a medical emergency. Facilities must be available for tracheal intubation and positive pressure respiration. Anticholinesterases must, of http://www.bmj.com/ Edrophonium Test course, be withheld and excessive muscarinic activity should be blocked by giving large doses of atropine. In these circum- For these reasons the edrophonium test is invaluable in diag- stances it is reasonable to give 2 mg atropine parenterally nosing paralytic problems in myasthenic patients. It may every hour until this treatment itself produces toxic effects. have to be resorted to repeatedly in titrating a patient's re- Cholinesterase reactivators have been produced as antidotes quirements of parenteral neostigmine. Even so, in employing for poisoning by certain organophosphorus insecticides and this test it is important that the response of essential "nerve"5 gases, and such agents-for example, pralidoxime- (respiratory and bulbar) muscles should be examined rather may be useful in cholinergic crises. A dose of 1-2 g of prali- on 5 October 2021 by guest. Protected copyright. than that of non-essential (limb or ocular) muscles. This pre- doxime may be given by slow intravenous injection over two caution is mandatory, because the same patient may have to four minutes. This may be repeated after 20 minutes if the weakness in some muscle groups because of inadequate response is transient or inadequate. Anticholinesterase drugs acetylcholine and simultaneous paralysis of muscle groups should not be started again until two successive edrophonium because of an excess of acetylcholine.' In other words, a tests have given a "myasthenic" type of response. cholingergic and myasthenic crisis may coexist in the same patient at the same time. Treatment Failures Myasthenic Crisis As already mentioned, failure to respond to anticholinesterases may be due to overdosage (cholinergic crisis). In some cases The myasthenic crisis is a medical emergency requiring imme- the cause of the development of "neostigmine insensitivity" diate availability of artificially assisted respiration. Traclleos- is more obscure. For example, patients may respond to tomy may prove necessary. A crisis may develop as a spon- edrop,honium with increased muscle power but function in taneous deterioration in the natural history of myastlieniia the corresponding muscles does not improve when longer- gravis, or it may be precipitated by infection, by exertion (as acting anticholinesterase agents are administered. Further- in childbirth), or by surgery. Drugs which exacerbate myas- more, the edrophonium test may be difficult to interpret, thenia gravis may also provoke a crisis. These include agents particularly if carried out within a short time of giving neo- which impair neuromuscular condition (such as streptomycin stigmine. Problems of this kind are especially likely to be or neomycin), substances which reduce the excitability of encountered in patients with fulminating myasthenia gravis muscle membrane (such as quinine or quinidine), and drugs with severe bulbar involvement, who readily develop which depress respiration (such as morphine or barbiturates). respiratory distress. Neostigmine resistance may occur at the It has also been claimed that menstruation, emotional stress, beginning of treatment, or it may develop at any stage after and thyrotoxicosis can precipitate rapid paralysis. starting therapy. Patients with this type of difficulty, or with 214 BRITISH MEDICAL JOURNAL 24 APRIL 1971 neostigmine requirements which undergo rapid fluctuation TREATMENT OF NEUROMUSCULAR DISTURBANCE (sometimes referred to as "brittle" myasthenics), represent a difficult therapeutic problem. Factors precipitating myasthenic Since the Eaton-Lambert syndrome is due to defective release crisis should naturally be avoided or treated, but patients of acetylcholine at the neuromuscular junction, theoretically Br Med J: first published as 10.1136/bmj.2.5755.213 on 24 April 1971. Downloaded from may still deteriorate inexorably into respiratory insufficiency. the myasthenia might be expected to improve with an anti- When the doctor is faced with the dilemma of failing cholinesterase, and in fact neostigmine has some therapeutic respiration and neostigmine resistance which cannot be action. Nevertheless, the response is not as satisfactory as in attributed to overdosage the patient should be curarized, myasthenia gravis, and in the Eaton-Lambert syndrome positive-pressure artificial respiration should be started, and better results may be obtained with guanidine-a drug which anticholinesterase drugs should be witheld. This treatment, has been shown to aid the release of acetylcholine at the which must be regarded as a last resort, generally results in motor nerve ending. a spontaneous resumption of responsiveness to neostigmine Guanidine should be given in divided oral doses of in three to ten days,2 after which the patient can be weaned 20-30 mg/kg/day. A reasonable initial regimen is 250 mg off the respirator. It has been suggested that "resting the end- three or four times a day, increasing according to individual plates" is the factor responsible for the improvement from tolerance. Maximum benefit is not attained until treatment this procedure. has been continued for several days and on stopping therapy Finally, long-standing cases of myasthenia gravis may improvement is correspondingly slow to disappear. At present ultimately progress to a myopathic disorder, in which there no suitable pharmaceutical form of guanidine is commercially is wasting, permanent weakness, and failure to respond to available. Preparations can be made fairly easily by a pharmacy anticholinesterase drugs. This condition presents as a chronic provided precautions are taken to deal with the deliquescence rather than an acute problem and is refactory to treatment. of guanidine.* The main adverse effects of treatment with guanidine are circumoral paraesthesiae, anorexia, diarrhoea, and an altered mental state-restlessness, agitation, and anxiety. More Infantile Myasthenia severe intoxication may cause vomiting, excessive salivation, tremor, hypoglycaemia, and circulatory disturbances. As in One out of every seven babies born to mothers with myas- the case of anticholinesterase overdosage, many unwanted thenia gravis has a syndrome of rapid shallow respiration actions of guanidine can be corrected by administration of with defective sucking and swallowing. The severity of the atropine. disorder of neuromuscular conductions is not related to that of the mother and the condition clears spontaneously over days or weeks. Nevertheless, the disease may prove fatal if Conclusion left untreated. An edrophonium test (1 mg intravenously) should confirm the diagnosis of infantile myasthenia and Myasthenia gravis and the Eaton-Lambert syndrome are anticholinesterase treatment should then be started with neurological
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