Drug Induce movement disorder

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<p>Drug induced movement disorderSurat tanprawate, MD, FRCP(T) Neurological center Chiangmai university</p> <p>+D1recepter</p> <p>Basal ganglia</p> <p>-D2recepter</p> <p>Direct pathway</p> <p>Indirect pathway</p> <p>NeurotransmitterFour classes of neurotransmitters: 1) Acetylcholine 2) Biogenic amines: serotonin, histamine, and the catecholamines - dopamine and norepinephrine 3) Excitatory amino acids - glutamate and aspartate, and inhibitory amino acids - gamma-aminobutyric acid (GABA), glycine and taurine 4) Neuropeptides, over 50 are known. Amino acid neurotransmitters are the most numerous</p> <p>Neuroleptic drugs Effects on cognition and behavior of antipsychotic drugs that reduce confusion, delusions, hallucinations, and psychomotor a gitation in patients with psychoses. 7 classes of drugs: Phenothiazines, further divided into the aliphatics, piperidines, and piperazines Thioxanthenes (eg, droperidol) Butyrophenones (eg, haloperidol) Dibenzoxazepines (eg, loxapine) Dihydroindolone (eg, molindone) Diphenylbutylpiperidine (eg, pimozide) Benzisoxazole (eg, risperidone)</p> <p>Pathophysiology: Their therapeutic actionAntagonism of central dopaminergic (D-2 receptor) neurotransmission Antagonist effects at muscarinic, serotonergic, alpha1-adrenergic, and H1-histaminergic receptors.</p> <p>Drug induced movement disorder (DIMD) Excessive motor activity(hyperkinesia or dyskinesia) Tremor Myoclonus Chorea Atetosis Ballism Tics Dystonia Parkinsonism</p> <p>Diminish spontaneous movement (bradykinesia)</p> <p>Class of drugs Neuroleptic drug Typical Atypical</p> <p> Non-neuroleptic drug</p> <p>Neuroleptic induced movement disorder Acute dystonia Acute akathisia Parkinsonism Neuroleptic malignant syndrome Tardive syndrome (tardive dyskinesia) Buccolinguomastigatory syndrome Tardive stereotype Tardive dystonia Tardive tourettism Tardive tremor Tardive myoclonus Tardive akathisia</p> <p>Neuroleptic induced acute dystonia Onset First few day</p> <p> Drug Neuroleptic drug (high potency) metoclopamide</p> <p> Risk Children Young adult</p> <p> Pathophysiology Sudden imbalance between striatal dopamine VS cholinergic system Relative preponderance of Ach</p> <p> Clinical Sustained involuntary muscle contraction Affect various body path Face, jaw, tongue, neck, throat Sustain deviation of the eye(oculogyric crisis) Limb dystonia Air way and respiratory muscle</p> <p> Treatment Drug withdrawal Parenteral anticholinergic: Benztropine Anti histamine:Diphenhydramine Muscle relaxant (BZD) in some case</p> <p>Neuroleptic induced akathisia Very common, very early, dose related SE Onset Few day</p> <p> Drug Neuroleptic (typical and atypical) Non-neuroleptic medication (SSRIs anti depressant) Dopamine receptor blockling drug</p> <p> Pathophysiology Not completely understood Complex interaction at the cortical-subcortical-spinal level</p> <p>Clinical Restlessness Wingging legs Pacing or rocking from foot to foot Stereotypies: involuntary movement that asr coordinated patterned, repetitive Seemingly purposeful but actually purposeless</p> <p> Involve trunk, legs, lower face, tongue</p> <p> Treatment Lower dose or switching to a less potent neuroleptic drugs BZP B-blocker Opiate clonidines</p> <p>Neuroleptic induced parkinsonism Dopamine antagonists (neuroleptic, antiemetics) Phenothiazine(chlorpromazine) Butyrophenone(haloperidol) Thioxanthenes(thiothixine) Substituted benzamides(metoclopramide) Reserpine Tetrabenazine Alpha-methydopa</p> <p>CCB with dopamine agonist activity Flunarizine, cinnarizine Diltiazem, captopril Amiodarone, procane Lithium Phenytoin Fluoxetine and SSRIs Ara-C Amphotericin B</p> <p>Others</p> <p>Dopamine depletors </p> <p> Risk factor Female Older age Greater drug potency Higher dose Genetic predisposition Previous brain injury</p> <p> Clinical Identical to the idiopathic form Clinical may diff Symmetrical S/S Associated with Rabbit syndrome or tremor of the mouth and jaw giving rise to peculiar chewing motion Concurrent TD</p> <p>Tardive syndrome Onset Chronic(&gt;3 Mo. of total cumulative neuroleptic exposure) Occur: during the course of Rx after dose reduction (unmask TD) after the causative drug has been withdrawal(covert or withdrawal TD)</p> <p> DDx with withdrawal dyskinesia Choreotic type dyskinesia Children Acute discontinuation of neuroleptic Short live, spontaneous remitting</p> <p> characteristic Persistent, sometime irriversible abnormal movement Hyperkinetic type: chorea, dystonia, tics, myoclonus, tremor Usually choreic in type Unaware of TD</p> <p> Region Orolinguomandibular, truncal, Limb region</p> <p>PathophysiologyLong term dopamine recepter blockage</p> <p>Increased number, affinity of post synaptic dopamine D2 recepter</p> <p>Drug that may cause Tardive dyskinesia</p> <p>Classification of Tardive dyskinesia Tardive dyskinesia Bucco-linguo-masticatory syndrome (BLMS)</p> <p> Tardive dyskinesia varients Tardive dystonia Tardive akathisia Tardive myoclonus Tardive tics Tardive tremor</p> <p>Bucco-linguo-masticatory syndrome (BLMS) Repetitive stereotyped movement of oral and facial movement Twisting and protrusion of tongue lip smacking and puckering and chewing</p> <p> Sometime spread to involve trunk and extremity Often uninvolved the upper face</p> <p>Tardive dystonia Clinical same as idiopathic dystonia Suspected in Hx. Exposure to anti-psychotic drug or dopamine receptor blocking drug Exclude secondary dystonia Focal, segmental, generalized</p> <p>Tardive tourettism Motor or vocal tics Simple voclization barking, clicking noise</p> <p> Complex verbal tics Coprolalia, echolalia, palilalia</p> <p>Tardive akathisia Inability to sit still accompanied by an inner sense of restlessness Fidgety, march in place Complex and stereotyped movement</p> <p>Tardive tremor Head, position, osillation Rabbit syndrome- 4-6Hz rhythm involve jaw, perinasal, perioral musculature( like chewing move of rabbit)</p> <p>Prognosis Persistent in most case Early detection Discontinue drugs Symptomatic treatment: dopamine depleting agent Reserpine (Serpasil) Metyrosine (Demser) Tetrabenasine (Nitoman)</p> <p>Management</p> <p>Clonazepam may useful in some case</p> <p>Others Phenytoin chorea, atetosis, dystonia, tremor, asterixis</p> <p>CNS stimulant Oropharyngeal dyskinesia tremor chorea</p> <p>TCA Choreoatetosis, tremor, myoclonus Myoclonus, chorea, dystonia, stereotype</p> <p>B-adrenergic agonists</p> <p>SSRIs</p> <p>OC</p>


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