A-Textbook-of-Clinical-Pharmacology-and-Therapeutics-5th-edition
A-Textbook-of-Clinical-Pharmacology-and-Therapeutics-5th-edition
A-Textbook-of-Clinical-Pharmacology-and-Therapeutics-5th-edition
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132 MOVEMENT DISORDERS AND DEGENERATIVE CNS DISEASE<br />
Table 21.2: Pharmacokinetics <strong>of</strong> donepezil, galantamine <strong>and</strong> rivastigmine<br />
Donepezil Galantamine (prolonged Rivastigmine<br />
release preparation)<br />
T max 4 hours 4 hours 1 hour<br />
Protein binding 90% 18% 40%<br />
CYP3A4 metabolites ✓ ✓ ✓<br />
Plasma t 1/2 unknown 70 hours 8 hours 2 hours a<br />
a Cholinesterase inhibition, duration 10 hours.<br />
Adverse effects<br />
With all three drugs, adverse effects are mainly a consequence<br />
<strong>of</strong> the cholinomimetic mechanism <strong>of</strong> action <strong>and</strong> are usually mild<br />
<strong>and</strong> transient. Nausea, vomiting <strong>and</strong> diarrhoea are common.<br />
Fatigue, dizziness, dyspepsia, urinary problems <strong>and</strong> syncope<br />
have been reported. Careful dose titration can improve tolerance.<br />
In overdose, a cholinergic crisis may develop including<br />
severe nausea, vomiting, abdominal pain, salivation, lacrimation,<br />
urination, defaecation, sweating, bradycardia, hypotension,<br />
collapse, convulsions <strong>and</strong> respiratory depression. In<br />
addition to supportive treatment, atropine should be administered<br />
which reverses most <strong>of</strong> the effects.<br />
Drug interactions<br />
Theoretically, donepezil might interact with a number <strong>of</strong><br />
other drugs that are metabolized by cytochrome P450, but at<br />
present there is no clinical evidence that this is important.<br />
MEMANTINE<br />
Memantine is an NMDA receptor antagonist used in moderate<br />
to severe dementia in AD <strong>and</strong> Parkinson’s disease. The<br />
National Institute for <strong>Clinical</strong> Excellence (NICE) does not recommend<br />
its use outside clinical trials.<br />
Key points<br />
Alzheimer’s disease<br />
• The prevalence <strong>of</strong> Alzheimer’s disease is increasing in<br />
ageing populations.<br />
• Currently, the principal therapeutic target is reduced<br />
cholinergic transmission.<br />
• Placebo-controlled studies in patients with mild or<br />
moderate Alzheimer’s disease <strong>of</strong> central cholinesterase<br />
inhibitors showed that scores <strong>of</strong> cognitive function<br />
were greater at three to six months in patients treated<br />
with the active drug. The clinical importance <strong>of</strong> this<br />
difference is uncertain.<br />
• The therapeutic benefits <strong>of</strong> cholinesterase inhibitors<br />
appear to be modest <strong>and</strong> have not yet been<br />
demonstrated to be sustained. Such therapy does not<br />
appear to affect underlying disease progression or<br />
mortality.<br />
Case history<br />
A 21-year-old woman was treated with an anti-emetic<br />
because <strong>of</strong> nausea <strong>and</strong> vomiting secondary to viral<br />
labyrinthitis. She received an initial intramuscular dose <strong>of</strong><br />
10 mg <strong>of</strong> metoclopromide <strong>and</strong> then continued on oral<br />
metoclopramide 10 mg three times a day, which relieved<br />
her nausea <strong>and</strong> vomiting. Two days later she was brought<br />
into the local Accident <strong>and</strong> Emergency Department<br />
because her husb<strong>and</strong> thought she was having an epileptic<br />
fit. Her arms <strong>and</strong> feet were twitching, her eyes were deviated<br />
to the left <strong>and</strong> her neck was twisted, but she opened<br />
her mouth <strong>and</strong> tried to answer questions. Muscle tone in<br />
the limbs was increased.<br />
Question<br />
What is the diagnosis here <strong>and</strong> what is the most appropriate<br />
<strong>and</strong> diagnostic acute drug treatment<br />
Answer<br />
Her posture, dystonia <strong>and</strong> head <strong>and</strong> ocular problems all<br />
point to a major dystonia with oculogyric crisis, almost certainly<br />
caused by metoclopramide. This side effect is more<br />
common in young women on high doses (a similar syndrome<br />
can occur with neuroleptics, such as prochlorperazine,<br />
used to treat nausea). It is probably due to excessive<br />
dopamine blockade centrally in a sensitive patient. It usually<br />
resolves within several hours <strong>of</strong> discontinuing the<br />
<strong>of</strong>fending drug, <strong>and</strong> in mild cases this is all that may be<br />
needed. In more severe cases, the treatment <strong>of</strong> choice is<br />
intravenous benztropine or procyclidine (anticholinergic<br />
agents), <strong>and</strong> further doses may be required, given orally.<br />
An alternative, equi-effective but less satisfactory therapy<br />
because it is not diagnostic is intravenous diazepam.<br />
FURTHER READING<br />
Citron M. Strategies for disease modification in Alzheimer’s disease.<br />
Nature Reviews. Neuroscience 2004; 5: 677–85.<br />
Nutt JG, Wooten GF. Diagnosis <strong>and</strong> initial managements <strong>of</strong><br />
Parkinson’s disease. New Engl<strong>and</strong> Journal <strong>of</strong> Medicine 2005; 353:<br />
1021–7.<br />
Richman D, Agius M. Treatment <strong>of</strong> autoimmune myasthenia gravis.<br />
Neurology 2003; 61: 1652–61.