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D-L and D-2 Agonists in Parkinson's Disease Abraham N

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D-L and D-2 Agonists in Parkinson's Disease Abraham N THE CANADIAN JOURNAL OF NEUROLOGICAL SCIENCES D-l and D-2 Agonists in Parkinson's Disease Abraham N. Lieberman, Menek Goldstein, Govindan Gopinathan and Andreas Neophytides ABSTRACT: We have evaluated 5 DA agonists-bromocriptine, lergotrile, lisuride, pergolide, and mesulergine in studies encompassing 278 patients with advanced PD. In most of our patients the DA agonist was added to levodopa. Most of our patients were no longer satisfactorily responding to levodopa. Previous attempts at managing these patients by changing the dose of levodopa (increasing or decreasing it), the treatment schedule, or the ratio of levodopa to carbidopa or by temporarily discontinuing levodopa [drug holiday] were unsuccessful. The majority of our patients had diurnal fluctuations in performance, either "wearing off or "on-off" phenomena. The addition of a DA agonist resulted in a decrease in parkinsonian disability in most patients and a decrease in the severity of the diurnal fluctuations in performance. Improvement in many patients was maintained for at least 2 years. Adverse effects included mental changes, dyskinesias, orthostatic hypotension, and nausea. All of the adverse effects were reversible when the agonist was decreased or discontinued. As a group the agonists behaved similarly but individual patients often responded better to one agonist than another. The main role of agonists is in combination with levodopa in the treatment of patients with early PD who have not yet developed dyskinesias or diurnal fluctuations in performance. RESUME: Les agonistes des recepteurs D-l et D-2 dans la maladie de Parkinson. Nous avons evalue 5 agonistes dopaminergiques—la bromocriptine, le lergotrile, le lisuride, le pergolide et la mesulergine par des etudes comprenant 278 patients souffrant d'une maladie de Parkinson avancee. Chez la plupart de nos patients, l'agoniste dopaminergique etait ajoute a la levodopa. La plupart de nos patients ne repondaient plus de fagon satisfaisante a la levodopa. Toutes les tentatives anterieures de controler la symptomatologie de ces patients en changeant la dose de levodopa (augmentation ou diminution), l'horaire de la prise du medicament, la proportion de levodopa par rapport a la carbidopa ou en retirant temporairement la levodopa [drug holiday] se sont soldees par un echec. La majorit6 de nos patients avaient des fluctuations dans la performance, du type "wearing off" ou epuisement ou du type "on-off. L'addition d'un agoniste dopaminergique a diminue 1'invalidite due a la maladie de Parkinson chez la plupart des patients et a diminue la severite des fluctuations diurnes dans la performance. L'amelioration chez plusieurs patients s'est maintenue pendant au moins 2 ans. Parmi les effets secondaires, on note les modifications de l'etat mental, les dyskinesies, I'hypotension orthostatique et les nausees. Tous les effets secondaires etaient reversibles lorsque la posologie de l'agoniste etait diminuee ou qu'il etait cesse. L'effet de tous les agonistes etait semblable, mais certains patients repondaient mieux a un agoniste qu'a un autre. Le role principal des agonistes est dans la therapie combinee avec la levodopa chez les patients qui sont au debut de leur maladie de Parkinson et qui n'ont pas encore developpe de dyskinesies ou de fluctuations diurnes dans la performance. can. J. Neurol. Sci. 1987-14:466-473 The efficacy of levodopa in Parkinson's disease (PD) decreases with long-term levodopa therapy is the development of diurnal after several years.' This decreased efficacy has been related fluctuations in performance, "wearing-off" and "on-off" both to disease progression and to the effects of levodopa itself. phenomena.6'7 One hypothesis attributes the fluctuations to The core disorder in PD is a degeneration of the pigmented inadequate delivery of DA to the postsynaptic striatal receptors. neurons in the substantia nigra compacta [SNC] and the locus Consequently, several approaches have been taken to augment 8 9 ceruleus. Paralleling the degeneration in the SNC is a loss of the delivery of levodopa to the striatum. ' These approaches dopamine (DA) and DA synthesizing enzymes in the SNC and include increasing the dose of levodopa, increasing the fre­ the striatum.2 Also the sensitivity of the postsynaptic DA recep­ quency of levodopaadministration, giving parenteral levodopa,10 tors may increase.3 Initially, levodopa may compensate for the using a controlled release le vodopa/carbidopa preparation, chang­ striatal DA deficiency by increasing the activity of the remain­ ing the levodopa/carbidopa ratio, using a different dopa decar­ 4 5 ing SNC neurons ' and may promote the formation of dopa­ boxylase inhibitor or dietary modification" to eliminate those mine in striatal intraneurons. Eventually, however, these amino acids that interfere with levodopa absorption.I2'l3 Another compensatory mechanisms fail. Another problem associated hypothesis attributes the decreased response to levodopa and From the New York University School of Medicine and New York Infirmary - Beekman Downtown Medical Center. New York Reprint requests to: Abraham N. Lieberman. 650 First Avenue. New York, New York, U.S.A. 10016 Downloaded466 from https://www.cambridge.org/core. IP address: 170.106.33.22, on 28 Sep 2021 at 18:35:52, subject to the Cambridge Core terms of use, available at https://www.cambridge.org/core/terms. https://doi.org/10.1017/S0317167100037938 LE JOURNAL CANADIEN DES SCIENCES NEUROLOGIQUES the diurnal fluctuations to chronic levodopa administration.I4,15 In these studies it was also demonstrated that although there Consequently there have been several approaches centering on are changes in the number of the D2 DA receptors, the binding decreasing or temporarily discontinuing levodopa.16 Thus far affinities of these receptors do not change. In addition the D| the benefits of all of these methods of augmenting the delivery DA receptors are unchanged or increased slightly by levodopa or decreasing the dose of levodopa have been limited. treatment. The D3 DA receptors are decreased by 30% to 50%. To date, the best results in patients with a decreasing response There are inherent limitations in understanding the mechanism to levodopa have been achieved with DA agonists, drugs that of action of levodopa and the DA agonists from these studies. bypass the degenerating SNC neurons and directly stimulate Further understanding of the action of levodopa and the DA the postsynaptic DA receptors. Even better results are achieved agonists has come from studies using animal models of when the DA agonists are used early, before the fluctuations parkinsonism. develop.I7 Because individual DA receptors may be concerned The existence of two types of striatal DA receptors with with specific therapeutic actions or adverse effects (in contrast opposite effects on cyclic AMP raises the question as to whether to the less specific action of levodopa) different DA agonists stimulation of the D| DA or the D2 DA receptor or both is could be directed toward specific D| or D2 DA receptors. Addi­ responsible for antiparkinsonian activity. Thus while recent tionally some of the DA agonists have a longer duration of studies indicate a 92 kilodalton (KDA) peptide may represent action than levodopa, and this itself may result in a smoother the binding site subunit of both receptors, biochemical, physio­ response. logical and behavioral studies with newly developed selective The D, DA receptor was initially identified as a DA sensitive D| and D2 DA agonists and antagonists indicate that there is a adenylate cyclase that was located in the superior cervical complex interaction between both receptors.22'23'26'27,28 For ganglion, the retina, and the striatum. Stimulation of the D| DA example the selective D, DA agonist, SKF 38393 enhances receptor results in an increased formation of cyclic adenosine cyclic AMP formation in striatal slices while the selective D2 monophosphate [AMP].18 There is good agreement between DA agonist, LY 141865 inhibits the SKF 38393 increased cyclic the antipsychotic activity of the phenothiazines and their activ­ AMP formation. Neither the D, DA agonist, SKF 38393 nor the ity as D| DA receptor blockers. This correlation does not D2 DA agonist LY 141865 restores locomotor activity in reser- extend to the butyrophenones or sulpiride, which are potent pinized mice, but the combined administration of these two antipsychotic agents but weak D| DA blockers. At the D| DA drugs does. Further, the selective D2 DA agonist LY 141865 site DA is a full agonist, apomorphine is a partial agonist [effective prevents the catalepsy that is induced by the selective D| DA mainly at denervated receptors] and bromocriptine is an antagonist SCH 23390 while the selective D, DA agonist blocks antagonist. In the striatum D| DA receptors are localized to the stereotyped behavior that is induced by D2 DA agonists. membranes of intrastriatal gamma amino butyric acid [GABA] Based on studies with these selective DA agonists and antago­ neurons. nists in animals and the available clinical data, it is not yet Stimulation of the D2 DA receptors does not result in increased possible to conclude whether stimulation of D| DA, D2 DA, or I9 cyclic AMP. D2 DA receptors are located in the striatum and both receptors is the most effective. Thus, dopamine (formed in the pituitary. Initially the striatal D2 DA receptors were from levodopa) and pergolide stimulate both the D| and D2 DA thought to be localized to axons of a descending cortico-striatal receptors, while bromocriptine, lergotrile, lisuride, ormesulergine 20 tract. Recent work suggests that these receptors may be on stimulate only the D2 DA receptors, None of the available DA intrastriatal GABA neurons.21 All of the major neuroleptic agonists, when used alone, is as effective as levodopa. However, antipsychotic drugs, including the phenothiazines, butyro­ several studies indicate that the DA agonists, when given in phenones, and sulpiride, are potent blockers of the D2 DA combination with levodopa, are more effective than levodopa receptors.
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