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Drug-Induced Parkinsonism

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Drug-Induced Parkinsonism REVIEW Print ISSN 1738-6586 / On-line ISSN 2005-5013 J Clin Neurol 2012;8:15-21 http://dx.doi.org/10.3988/jcn.2012.8.1.15 Open Access Drug-Induced Parkinsonism Hae-Won Shin,a Sun Ju Chungb aDepartment of Neurology, Chung-Ang University College of Medicine, Seoul, Korea bParkinson/Alzheimer Center, Department of Neurology, University of Ulsan College of Medicine, Seoul, Korea Drug-induced parkinsonism (DIP) is the second-most-common etiology of parkinsonism in the el- derly after Parkinson’s disease (PD). Many patients with DIP may be misdiagnosed with PD be- cause the clinical features of these two conditions are indistinguishable. Moreover, neurological deficits in patients with DIP may be severe enough to affect daily activities and may persist for long periods of time after the cessation of drug taking. In addition to typical antipsychotics, DIP may be caused by gastrointestinal prokinetics, calcium channel blockers, atypical antipsychotics, and anti- epileptic drugs. The clinical manifestations of DIP are classically described as bilateral and sym- metric parkinsonism without tremor at rest. However, about half of DIP patients show asymmetri- Received April 8, 2011 cal parkinsonism and tremor at rest, making it difficult to differentiate DIP from PD. The pathophy- Revised June 28, 2011 siology of DIP is related to drug-induced changes in the basal ganglia motor circuit secondary to Accepted June 28, 2011 dopaminergic receptor blockade. Since these effects are limited to postsynaptic dopaminergic re- Correspondence ceptors, it is expected that presynaptic dopaminergic neurons in the striatum will be intact. Dopa- Sun Ju Chung, MD, PhD mine transporter (DAT) imaging is useful for diagnosing presynaptic parkinsonism. DAT uptake in Department of Neurology, the striatum is significantly decreased even in the early stage of PD, and this characteristic may help Asan Medical Center, in differentiating PD from DIP. DIP may have a significant and longstanding effect on patients’ University of Ulsan daily lives, and so physicians should be cautious when prescribing dopaminergic receptor block- College of Medicine, ers and should monitor patients’ neurological signs, especially for parkinsonism and other move- 88 Olympic-ro 43-gil, ment disorders. J Clin Neurol 2012;8:15-21 Songpa-gu, Seoul 138-736, Korea Tel +82-2-3010-3988 Key WordszzParkinsonism, dopamine receptor blocking agents, clinical manifestations, Fax +82-2-474-4691 dopamine transporter imaging, treatment. E-mail [email protected] Introduction was to provide clinicians with updated information about the clinical characteristics and DAT imaging findings of patients Drug-induced movement disorders include drug-induced parkin- with DIP, and about the correct treatment for DIP. sonism (DIP), tardive dyskinesia (TD), tardive dystonia, akathisia, myoclonus, and tremor. Among these, DIP is the most common Epidemiology of Drug-Induced movement disorder induced by drugs that affect dopamine re- Parkinsonism ceptors.1-3 Since the clinical manifestations of DIP are very sim- ilar to those of Parkinson’s disease (PD), patients with DIP are The exact prevalence and incidence of DIP are unclear be- frequently misdiagnosed as having PD.1,4 These patients are of- cause it is frequently unrecognized or misdiagnosed as PD. The ten prescribed antiparkinsonian drugs unnecessarily for long first study of the extrapyramidal side effects (EPS) of the anti- periods of time, despite recovery being possible simply by dis- psychotic chlorpromazine found that about 40% of these pa- continuing the offending drugs. Dopamine transporter (DAT) im- tients exhibited parkinsonism,7 and several subsequent epide- aging may be used in the differential diagnosis of various eti- miological studies found that DIP is the second most common ologies of parkinsonism, including DIP.5,6 The aim of this review etiology of parkinsonism.8-10 A community-based survey and a cc This is an Open Access article distributed under the terms of the Cre- population-based study found DIP prevalence rates of 2.7% and ative Commons Attribution Non-Commercial License (http://creative- 1.7%, respectively, whereas those of PD were 3.3% and 4.5%, ) commons.org/licenses/by-nc/3.0 which permits unrestricted non-com- respectively.8-10 However, 6.8% of the patients diagnosed with mercial use, distribution, and reproduction in any medium, provided the ori- ginal work is properly cited. PD were later reclassified as having DIP, thus emphasizing the Copyright © 2012 Korean Neurological Association 15 Drug-Induced Parkinsonism difficulties in accurately diagnosing DIP and in measuring its chotics have some risk of developing parkinsonism and other prevalence.4 Age is the most obvious risk factor for DIP,11-13 EPS. Parkinsonism usually appears days to weeks after starting since dopamine concentrations decrease and nigral cells degen- antipsychotics, but in rare cases the onset delay may be several erate with age.14 Another risk factor is female gender,8,15-17 sug- months or more. The risk of EPS was thought to be low for atypi- gesting that estrogen suppresses the expression of dopamine cal antipsychotics. Atypical antipsychotics include clozapine, receptors;18 however, the exact mechanism underlying the gen- risperidone, olanzapine, quetiapine, and aripiprazole. It was orig- der difference in DIP remains to be clarified. Genetic factors inally thought that their relatively low frequency of associated are also thought to be involved in the development of DIP be- EPS was due to them being more strongly antagonistic toward cause not all patients taking dopamine receptor blocking agents serotonin-2A receptors than toward dopamine receptors.25-27 (DRBAs) develop parkinsonism.19-21 Genome-wide screening This serotonin-dopamine hypothesis has long been considered showed that the genes associated with the gamma-aminobu- a useful model for developing atypical antipsychotics that ex- tyric acid (GABA) receptor signaling pathway are involved in hibit superior antipsychotic efficacy with a lower incidence of neuroleptic-induced TD in schizophrenic patients,21 suggesting EPS compared to typical antipsychotics.25-27 The recent ‘fast- that genetic factors predispose to both DIP and TD. off’ theory suggested that their rapid dissociation from D2 re- ceptors after they have blocked them can explain their lower Etiology of Drug-Induced risk of EPS.28,29 Parkinsonism In 1989, clozapine became the first atypical antipsychotic drug to be approved by the US Food and Drug Administra- Typical antipsychotics, also known as neuroleptics, are the most tion.26 It is effective in schizophrenia patients with drug-resis- common causes of DIP. However, atypical antipsychotics, which tant negative symptoms, with an almost complete absence of were thought to be free from EPS, can also induce parkinson- EPS. DIP due to clozapine has not been reported, and it was ism. In addition to antipsychotics, gastrointestinal (GI) motility found to improve psychosis without aggravating parkinsonism drugs, calcium channel blockers (CCBs), and antiepileptic even in PD patients.30 However, clozapine has been associated drugs have been found to induce DIP (Table 1). with agranulocytosis in about 1% of patients, making physi- cians reluctant to prescribe this drug. Other atypical antipsy- Antipsychotic drugs chotics without the risk of agranulocytosis were developed to The history of DIP parallels that of antipsychotics. Parkinson- control psychosis with minimal EPS. Risperidone was expect- ism as a side effect of chlorpromazine was first reported 3 ed to have a minimal risk of EPS because it has a high affinity 7 31 years after its introduction. It was soon recognized that all typ- for serotonin receptors. However, it binds D2 receptors in a ical antipsychotics had the potential to cause EPS, including dose-dependent manner, thus inducing parkinsonism and EPS parkinsonism, acute dystonia, akathisia, and TD.7,22,23 Typical to a similar extent as high doses of typical antipsychotics.31 Al- antipsychotics include chlorpromazine, promazine, haloperi- though the molecular structure of olanzapine is similar to that dol, perphenazine, fluphenazine, and pimozide. About 80% of of clozapine, it carries with it a significant risk of EPS.32 Que- patients taking typical antipsychotic drugs exhibit more than tiapine is an atypical antipsychotic with a low risk of EPS and one kind of EPS.24 Dopamine receptors are widely distributed a low risk of aggravation of parkinsonism when used to treat in the brain, and typical antipsychotics may act on dopamine psychotic symptoms in patients with PD, and is therefore ap- receptors in the striatum. Therefore, all patients taking antipsy- parently safe for use in elderly patients.33,34 Aripiprazole is the Table 1. Common offending drugs of drug-induced parkinsonism Drug frequently causing parkinsonism Drug infrequently causing parkinsonism Typical antipsychotics Phenothiazine: chlorpromazine, prochlorperazine, Atypical antipsychotics Clozapine, quetiapine perphenazine, fluphenazine, promethazine Butyrophenones: haloperidol Diphenylbutylpiperidine: pimozide Mood stabilizer Lithium Benzamide substitutes: sulpiride Atypical antipsychotics Risperidone, olanzapine, Antidepressant SSRI: citalopram, fluoxetine, ziprasidone, aripiprazole praoxetine, sertraline Dopamine depleters Reserpine, tetrabenazine Antiepileptic drugs Valproic acid, phenytoin Antiemetics Metoclopramide, levosulpiride, clebopride Antiemetics Domperidone, itopride Calcium-channel blocker Flunarizine,
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