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2.285 TRANSDERMAL ROTIGOTINE CAUSES IMPULSE CONTROL DISORDERS IN PATIENTS WITH RESTLESS LEGS SYNDROME
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Tuesday, 13 December 2011 / Parkinsonism and Related Disorders 18S2 (2012) S81–S159
Results: We present the case of a 85 year old patient with a diagnosis of PD, who noticed the presence hair darkening of the temporal hair during treatment with macuna pruriens extract at a daily dose equivalent to 600 mg of levodopa (Figure). In her adulthood her natural hair was brown, with ageing it became completely white. Now the area of dark hair was black, much darker that her natural hair as an adult. As months passed while using the extract, the area became larger and the color darker. Motor function, however, remained unchanged. Conclusion: Hair darkening may be a complication of use of over the counter dietary supplements containing levodopa. 2.282 FACTORS RELATED TO ORTHOSTATIC HYPOTENSION IN PARKINSON’S DISEASE S. Perez-Lloret1 , M.V. Rey2 , N. Fabre3 , F. Ory3 , U. Spampinato4 , J.-L. Montastruc2 , O. Rascol2 . 1 Clinical Pharmacology, CHU Toulouse, 2 Department of Pharmacology, Paul Sabatier University, 3 CHU Toulouse, Toulouse, 4 CHU Bordeaux, Bordeaux, France Introduction: Orthostatic hypotension (OH), a frequent feature of Parkinson’s disease (PD) can contribute to falls and is related to the disease itself or to drugs. Objectives: To assess the concordance between abnormal BP fall after orthostatism and the presence of hypotensive symptoms as well as to explore factors related to the presence of OH. Methods: Non-demented, non-operated PD out-patients were questioned about the presence of hypotensive symptoms. Afterwards, BP was measured 5 min after lying down and 3 min after standing up. OH was defined as systolic and/or diastolic BP fall ≥20 and/or 10 mmHg after orthostatism. Patients were further evaluated by the Unified PD rating scale and their medications were recorded. Results: 103 patients were included in this study (mean age = 66±1 years, mean disease duration = 9±1 years; mean UPDRS II+III in ON-state = 37±2 points). Forty-one subjects (40%) reported hypotensive symptoms and 38 (37%) had OH. The agreement between abnormal BP fall and presence of symptoms was low (kappa = 0.12±0.1, p = 0.2). Independent factors related to OH as assessed by logistic regression were age >68 years (OR, 95%CI = 3.61, 1.31–9.95), polypharmacy (defined as intake of more than 6 medications, OR = 3.59, 1.33–9.69), amantadine (7.45, 1.91–29.07) or diuretics (OR not calculable), whereas COMT inhibitors were protective (0.20, 0.05–0.76). Conclusion: Low concordance between OH and hypotensive symptoms was observed. The former was related to older age and pharmacological treatments such as amantadine, diuretics or polypharmacy. COMT inhibitors reduced OH risk. 2.283 REVERSIBLE ANTECOLLIS ASSOCIATED WITH DOPAMINE AGONIST IN A PATIENT WITH PARKINSON’S DISEASE H.J. Kim1 , B.S. Jeon2 , H.J. Kang3 , J.-Y. Kim4 , S.H. Kim1 , S.-H. Han1 . 1 Neurology, Konkuk University Hospital, 2 Neurology, Seoul National University Hospital, Seoul National University College of Medicine, 3 Neurology, Ewha Womans University Medical Center, 4 Neurology, Inje University Seoul Paik Hospital, Seoul, Republic of Korea Introduction: Antecollis is a frequent complication in multiple system atrophy, but rare in Parkinson’s disease. We report reversible antecollis induced by pramipexole in a patient with Parkinson’s disease. Case report: A 77-year-old woman developed jaw tremor and rest tremor of her right hand. One year later, she was diagnosed with Parkinson’s disease and started treatment with levodopa, which significantly improved her parkinsonism. At the age of 80, 1 mg of pramipexole was added because of restless leg syndrome. Six weeks after taking pramipexole, antecollis appeared subacutely. When she visited an outpatient clinic, she had prominent antecollis, cogwheel
rigidity on right side, and mild bradykinesia. She had mild weakness of neck extension in the sitting position, but, normal strength in the supine position. She could lift up her head temporally with effort. Electromyography of the posterior and anterior neck muscles showed normal motor unit potentials and no definite neurogenic or myopathic change except for mild positive sharp waves in the C5 paraspinal muscles. Pramipexole was withdrawn immediately and one week later, antecollis dramatically improved. Conclusion: Our case highlights the importance of considering dopamine agonists as a possible cause in the development of antecollis and suggests that immediate withdrawal of the offending drugs may reverse this symptom. 2.284 IMPULSE-CONTROL DISORDERS IN PARKINSON’S DISEASE PATIENTS S. Perez-Lloret1 , M.V. Rey2 , N. Fabre3 , F. Ory3 , U. Spampinato4 , J.-L. Montastruc2 , O. Rascol2 . 1 Clinical Pharmacology, CHU Toulouse, 2 Department of Pharmacology, Paul Sabatier University, 3 CHU Toulouse, Toulouse, 4 CHU Bordeaux, Bordeaux, France Background: Impulse-control disorders (ICD) can occur with any dopaminergic drug in Parkinson’s Disease (PD), specially in younger patients. Objective: To assess the prevalence of ICD in a sample of PD and non-PD patients and to evaluate the factors related to their occurrence. Methods: Ambulatory non-demented, non-operated PD or stroke outpatients recruited at the Toulouse University hospital, were systematically questioned about compulsive behaviors related to punding, hypersexuality, compulsive shopping (CS), pathological gambling (PG) or binge eating (BE). Full medical history and UPDRS were performed. Results: 203 PD patients and 44 non-PD were recruited (age: 69 2 vs 67 1 y p = 0.3, males: 55% vs 62% p = 0.4). In PD, mean disease duration was 9±1 years, mean UPDRS II+III in ON-state was 37±2. Eight % of patients were on MAOB Inhibitors (MAOBI), 80% on agonists or 90% on levodopa. ICDs were reported by 0% of non-PD and 21.2% of PD (punding: 3.2%, hypersexuality: 8.2%, PG: 2.0%, comp.shopping: 5.3%, BE: 11.4%). PD patients with ICDs were younger (p < 0.001), more frequently on agonists (p < 0.001), had higher levodopa equivalent dose (p < 0.05) and more frequently on a MAO-B inhibitor (p < 0.05). A logistic regression analysis disclosed that age >68 years (OR=0.3, 0.1–0.6) and treatment with MAOBI (3.7, 1.1–12.6) or dopamine agonists were the only significant factors related to ICD. Conclusions: Prevalence of ICD in our sample of PD patients was high (21%), while non post-stroke patient had this type of ADR. Age and treatment with ropinirole or MAO-B inhibitors increased ICD risk. 2.285 TRANSDERMAL ROTIGOTINE CAUSES IMPULSE CONTROL DISORDERS IN PATIENTS WITH RESTLESS LEGS SYNDROME S.R. Schreglmann, A.R. Gantenbein, C.R. Baumann. Neurology, University Hospital Zurich, Zurich, Switzerland Introduction: Dopaminergic drugs are the mainstay of treatment for restless legs syndrome (RLS). We analyzed the frequency and clinical characteristics of impulse control disorders (ICD) in patients with RLS on transdermal rotigotine treatment. Methods: Retrospective case series at a university movement disorder clinic (n = 28, 17 women). Symptoms of ICD were assessed via detailed history taking and scoring with the Zurich Screening Questionnaire for ICD prior to and after initiation of treatment. Results: None of the patients had a history of ICD prior to treatment. Baseline mean scores for patients who did (8.0±2.5) and did not (6.2±2.7) develop ICD under treatment did not differ. Six male patients (21%) developed various symptoms of ICD (mean
Tuesday, 13 December 2011 / Parkinsonism and Related Disorders 18S2 (2012) S81–S159
scores 20.7±10.2) on rotigotine treatment (mean dose: 3.8 mg/d), including binge eating, hypersexuality, compulsive shopping, pathological gambling, and punding, equaling a prevalence rate of 21%. Also in the the non-ICD group ZICD scores increased (7.5±2.8). Conclusion: This is the first report of ICD in patients treated with transdermal rotigotine for RLS. In contrast to literature, even low doses of rotigotine (mean 3.8 mg/d) can cause ICD. Therefore every prescribing physician should be aware that ICD may emerge in both RLS and PD patients on any dopaminergic treatment, and should actively ask for such symptoms. The ZICD questionnaire not only replicated the findings of detailed history taking but also showed an increased tendency towards impulsive behaviour in subjects that did not develop ICD.
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Methods: Case Report. Results: An 80-year-old man with a 15 year history of PD, experiencing complications of levodopa therapy (wearingoff phenomenon and peak-dose dyskinesias), was initiated on rotigotine patch (2 mg, titrated up to 6 mg/day). While this drug brought significant motor improvement, bilateral nail dyschromia with green nail (figure 1) discoloration was noticed within days after the change in therapeutic regimen. Two months after rotigotine withdrawal, ND completely disappeared (figure 2).
2.286 MIGRATORY EDEMA REALATED TO RASAGILINE TREATMENT M.J. Catalan, E. Lopez-Valdes, C. Villanueva, R. Garcia-Ramos. Neurology Department, Hospital Clinico San Carlos, Madrid, Spain Objective: Rasagiline, a selective MAO-B inhibitor, is usually well tolerated in Parkinson’s disease (PD). Few side effects have been reported in relation to its use. We present a patient with advanced PD, that develop a peripheral edema while he was in treatment with rasagilina. Materials: A 73 years old man with Parkinson disease of 7 years of evolution. He started on rasagiline and levodopa-carbidopa treatment and one year later he started with fluctuations. Levodopa daily doses were increased, and he needed levodopa in a 3 three hours schedule during the waking time. After 2 years he developed a left forearm swelling accompanied by itching and redness, following after few days, with extension to the hand and contralateral pretibial region. Pretibial and forearm oedema comes and goes and later resolved spontaneously. Hand oedema remained. Results: The patient was thoroughly studied with a complete analysis, vascular study and skin biopsy. No cause was found. Because the fluctuating response, nine months later the patient was changed to Jejunal duodopa infusion. At that point, rasagiline was stopped. Three days after stopped rasagiline the oedema resolved completely. Conclusion: We report a new secondary effect in relationship to rasagiline. MAO-A inhibitor drugs have been linked to peripheral oedema, but has not been related with the MAO-B inhibitor rasagiline. Oedema has been related with dopaminergic agonist, some times after a longer use, but usually symmetrical in both legs. Furthermore the localized and migratory asymmetric hand oedema is not usually a drug side effect. 2.287 ROTIGOTINE-INDUCED NAIL DYSCHROMIA IN A PATIENT WITH PARKINSONS DISEASE R.P. Munhoz, H.A.G. Teive. Federal University of Parana, Curitiba, Brazil Background: Rotigotine is the first non-ergot derived dopamine agonist administered via transdermal patch technology, indicated for use in early and advanced PD. The potential advantages of rotigotine include immediate effect onset, constant drug delivery, and ease of use, once-daily adhesive patch. Rotigotine demonstrated efficacy and safety as monotherapy in PD to reduce duration of OFF periods. Rotigotine has high affinity for dopamine D(2) and D(3) receptors. The most commonly reported adverse event are application-site reactions, somnolence and nausea. Druginduced nail abnormalities, particularly nail dyschromia, are wellknown complications related to several drugs, including zidovudine, cancer chemotherapies, retinoids, tetracycline and minocycline. The objective of this study is to present for the first time an unusual complication related to treatment of Parkinson’s disease (PD) with rotigotine transdermal patch.
Figure 1.
Figure 2. Conclusions: The close cause and effect relationship found in the case presented here demonstrates that rotigotine transdermal may be associated with nail dyschromia. Clinicians prescribing this drug should be aware of this reversible complication. 2.288 COMBINED ZOLPIDEM AND CARBIDOPA/LEVODOPA TREATMENT OF PROGRESSIVE SUPRANUCLEAR PALSY (PSP): A CASE REPORT WITH VIDEO DOCUMENTATION S. Chen1 , S. Juneja2 , S.L. Jaffe1 . 1 Neurology, 2 Medical School, Louisiana State University School of Medicine, Shreveport, LA, USA Introduction: PSP is characterized by ocular (supranuclear gaze palsies), motor (bradykinesia/akinesia, rigidity, postural impairment, extensor dystonia), and pseudobulbar (dysarthria, dysphagia) symptoms/signs in addition to frontal lobe/cognitive/personality impairment. Carbidopa/levodopa is the primary treatment medication although benefits are limited (striatal D2 receptor loss). In addition to dopaminergic and cholinergic circuitry, gabanergic circuitry is also affected in the PSP brain. A case of severe PSP was treated with zolpidem, a selective agonist of the benzodiazepine receptor (BZ1) on the GABA-A receptor complex, alpha subunit, and carbidopa/levodopa. Video documentation was obtained. Method: Case Report – A 63 year old man, end-stage/typical PSP, symptomatic for 4 years, with classical findings on brain MRI was treated with zolpidem IR, 5 mg, together with carbidopa/levodopa, 25/250, three times a day (7AM, Noon, and 5PM, i.e. q 5 hrs). Video documentation was obtained during baseline treatment with carbidopa/levodopa, and at 1 and 2 days after combination treatment. Results: Carbidopa/levodopa improved akinesia, limb rigidity, dysarthria and dysphagia. These benefits were augmented by adding zolpidem, and further immediate improvement (maximizing in 1 hour, lasting 5 hours) was observed in horizontal eye movement, facial expression, akinesia, limb and especially axial rigidity/extensor dystonia, resulting in the patient sitting, standing
Tuesday, 13 December 2011 / Parkinsonism and Related Disorders 18S2 (2012) S81–S159
Results: We present the case of a 85 year old patient with a diagnosis of PD, who noticed the presence hair darkening of the temporal hair during treatment with macuna pruriens extract at a daily dose equivalent to 600 mg of levodopa (Figure). In her adulthood her natural hair was brown, with ageing it became completely white. Now the area of dark hair was black, much darker that her natural hair as an adult. As months passed while using the extract, the area became larger and the color darker. Motor function, however, remained unchanged. Conclusion: Hair darkening may be a complication of use of over the counter dietary supplements containing levodopa. 2.282 FACTORS RELATED TO ORTHOSTATIC HYPOTENSION IN PARKINSON’S DISEASE S. Perez-Lloret1 , M.V. Rey2 , N. Fabre3 , F. Ory3 , U. Spampinato4 , J.-L. Montastruc2 , O. Rascol2 . 1 Clinical Pharmacology, CHU Toulouse, 2 Department of Pharmacology, Paul Sabatier University, 3 CHU Toulouse, Toulouse, 4 CHU Bordeaux, Bordeaux, France Introduction: Orthostatic hypotension (OH), a frequent feature of Parkinson’s disease (PD) can contribute to falls and is related to the disease itself or to drugs. Objectives: To assess the concordance between abnormal BP fall after orthostatism and the presence of hypotensive symptoms as well as to explore factors related to the presence of OH. Methods: Non-demented, non-operated PD out-patients were questioned about the presence of hypotensive symptoms. Afterwards, BP was measured 5 min after lying down and 3 min after standing up. OH was defined as systolic and/or diastolic BP fall ≥20 and/or 10 mmHg after orthostatism. Patients were further evaluated by the Unified PD rating scale and their medications were recorded. Results: 103 patients were included in this study (mean age = 66±1 years, mean disease duration = 9±1 years; mean UPDRS II+III in ON-state = 37±2 points). Forty-one subjects (40%) reported hypotensive symptoms and 38 (37%) had OH. The agreement between abnormal BP fall and presence of symptoms was low (kappa = 0.12±0.1, p = 0.2). Independent factors related to OH as assessed by logistic regression were age >68 years (OR, 95%CI = 3.61, 1.31–9.95), polypharmacy (defined as intake of more than 6 medications, OR = 3.59, 1.33–9.69), amantadine (7.45, 1.91–29.07) or diuretics (OR not calculable), whereas COMT inhibitors were protective (0.20, 0.05–0.76). Conclusion: Low concordance between OH and hypotensive symptoms was observed. The former was related to older age and pharmacological treatments such as amantadine, diuretics or polypharmacy. COMT inhibitors reduced OH risk. 2.283 REVERSIBLE ANTECOLLIS ASSOCIATED WITH DOPAMINE AGONIST IN A PATIENT WITH PARKINSON’S DISEASE H.J. Kim1 , B.S. Jeon2 , H.J. Kang3 , J.-Y. Kim4 , S.H. Kim1 , S.-H. Han1 . 1 Neurology, Konkuk University Hospital, 2 Neurology, Seoul National University Hospital, Seoul National University College of Medicine, 3 Neurology, Ewha Womans University Medical Center, 4 Neurology, Inje University Seoul Paik Hospital, Seoul, Republic of Korea Introduction: Antecollis is a frequent complication in multiple system atrophy, but rare in Parkinson’s disease. We report reversible antecollis induced by pramipexole in a patient with Parkinson’s disease. Case report: A 77-year-old woman developed jaw tremor and rest tremor of her right hand. One year later, she was diagnosed with Parkinson’s disease and started treatment with levodopa, which significantly improved her parkinsonism. At the age of 80, 1 mg of pramipexole was added because of restless leg syndrome. Six weeks after taking pramipexole, antecollis appeared subacutely. When she visited an outpatient clinic, she had prominent antecollis, cogwheel
rigidity on right side, and mild bradykinesia. She had mild weakness of neck extension in the sitting position, but, normal strength in the supine position. She could lift up her head temporally with effort. Electromyography of the posterior and anterior neck muscles showed normal motor unit potentials and no definite neurogenic or myopathic change except for mild positive sharp waves in the C5 paraspinal muscles. Pramipexole was withdrawn immediately and one week later, antecollis dramatically improved. Conclusion: Our case highlights the importance of considering dopamine agonists as a possible cause in the development of antecollis and suggests that immediate withdrawal of the offending drugs may reverse this symptom. 2.284 IMPULSE-CONTROL DISORDERS IN PARKINSON’S DISEASE PATIENTS S. Perez-Lloret1 , M.V. Rey2 , N. Fabre3 , F. Ory3 , U. Spampinato4 , J.-L. Montastruc2 , O. Rascol2 . 1 Clinical Pharmacology, CHU Toulouse, 2 Department of Pharmacology, Paul Sabatier University, 3 CHU Toulouse, Toulouse, 4 CHU Bordeaux, Bordeaux, France Background: Impulse-control disorders (ICD) can occur with any dopaminergic drug in Parkinson’s Disease (PD), specially in younger patients. Objective: To assess the prevalence of ICD in a sample of PD and non-PD patients and to evaluate the factors related to their occurrence. Methods: Ambulatory non-demented, non-operated PD or stroke outpatients recruited at the Toulouse University hospital, were systematically questioned about compulsive behaviors related to punding, hypersexuality, compulsive shopping (CS), pathological gambling (PG) or binge eating (BE). Full medical history and UPDRS were performed. Results: 203 PD patients and 44 non-PD were recruited (age: 69 2 vs 67 1 y p = 0.3, males: 55% vs 62% p = 0.4). In PD, mean disease duration was 9±1 years, mean UPDRS II+III in ON-state was 37±2. Eight % of patients were on MAOB Inhibitors (MAOBI), 80% on agonists or 90% on levodopa. ICDs were reported by 0% of non-PD and 21.2% of PD (punding: 3.2%, hypersexuality: 8.2%, PG: 2.0%, comp.shopping: 5.3%, BE: 11.4%). PD patients with ICDs were younger (p < 0.001), more frequently on agonists (p < 0.001), had higher levodopa equivalent dose (p < 0.05) and more frequently on a MAO-B inhibitor (p < 0.05). A logistic regression analysis disclosed that age >68 years (OR=0.3, 0.1–0.6) and treatment with MAOBI (3.7, 1.1–12.6) or dopamine agonists were the only significant factors related to ICD. Conclusions: Prevalence of ICD in our sample of PD patients was high (21%), while non post-stroke patient had this type of ADR. Age and treatment with ropinirole or MAO-B inhibitors increased ICD risk. 2.285 TRANSDERMAL ROTIGOTINE CAUSES IMPULSE CONTROL DISORDERS IN PATIENTS WITH RESTLESS LEGS SYNDROME S.R. Schreglmann, A.R. Gantenbein, C.R. Baumann. Neurology, University Hospital Zurich, Zurich, Switzerland Introduction: Dopaminergic drugs are the mainstay of treatment for restless legs syndrome (RLS). We analyzed the frequency and clinical characteristics of impulse control disorders (ICD) in patients with RLS on transdermal rotigotine treatment. Methods: Retrospective case series at a university movement disorder clinic (n = 28, 17 women). Symptoms of ICD were assessed via detailed history taking and scoring with the Zurich Screening Questionnaire for ICD prior to and after initiation of treatment. Results: None of the patients had a history of ICD prior to treatment. Baseline mean scores for patients who did (8.0±2.5) and did not (6.2±2.7) develop ICD under treatment did not differ. Six male patients (21%) developed various symptoms of ICD (mean
Tuesday, 13 December 2011 / Parkinsonism and Related Disorders 18S2 (2012) S81–S159
scores 20.7±10.2) on rotigotine treatment (mean dose: 3.8 mg/d), including binge eating, hypersexuality, compulsive shopping, pathological gambling, and punding, equaling a prevalence rate of 21%. Also in the the non-ICD group ZICD scores increased (7.5±2.8). Conclusion: This is the first report of ICD in patients treated with transdermal rotigotine for RLS. In contrast to literature, even low doses of rotigotine (mean 3.8 mg/d) can cause ICD. Therefore every prescribing physician should be aware that ICD may emerge in both RLS and PD patients on any dopaminergic treatment, and should actively ask for such symptoms. The ZICD questionnaire not only replicated the findings of detailed history taking but also showed an increased tendency towards impulsive behaviour in subjects that did not develop ICD.
S137
Methods: Case Report. Results: An 80-year-old man with a 15 year history of PD, experiencing complications of levodopa therapy (wearingoff phenomenon and peak-dose dyskinesias), was initiated on rotigotine patch (2 mg, titrated up to 6 mg/day). While this drug brought significant motor improvement, bilateral nail dyschromia with green nail (figure 1) discoloration was noticed within days after the change in therapeutic regimen. Two months after rotigotine withdrawal, ND completely disappeared (figure 2).
2.286 MIGRATORY EDEMA REALATED TO RASAGILINE TREATMENT M.J. Catalan, E. Lopez-Valdes, C. Villanueva, R. Garcia-Ramos. Neurology Department, Hospital Clinico San Carlos, Madrid, Spain Objective: Rasagiline, a selective MAO-B inhibitor, is usually well tolerated in Parkinson’s disease (PD). Few side effects have been reported in relation to its use. We present a patient with advanced PD, that develop a peripheral edema while he was in treatment with rasagilina. Materials: A 73 years old man with Parkinson disease of 7 years of evolution. He started on rasagiline and levodopa-carbidopa treatment and one year later he started with fluctuations. Levodopa daily doses were increased, and he needed levodopa in a 3 three hours schedule during the waking time. After 2 years he developed a left forearm swelling accompanied by itching and redness, following after few days, with extension to the hand and contralateral pretibial region. Pretibial and forearm oedema comes and goes and later resolved spontaneously. Hand oedema remained. Results: The patient was thoroughly studied with a complete analysis, vascular study and skin biopsy. No cause was found. Because the fluctuating response, nine months later the patient was changed to Jejunal duodopa infusion. At that point, rasagiline was stopped. Three days after stopped rasagiline the oedema resolved completely. Conclusion: We report a new secondary effect in relationship to rasagiline. MAO-A inhibitor drugs have been linked to peripheral oedema, but has not been related with the MAO-B inhibitor rasagiline. Oedema has been related with dopaminergic agonist, some times after a longer use, but usually symmetrical in both legs. Furthermore the localized and migratory asymmetric hand oedema is not usually a drug side effect. 2.287 ROTIGOTINE-INDUCED NAIL DYSCHROMIA IN A PATIENT WITH PARKINSONS DISEASE R.P. Munhoz, H.A.G. Teive. Federal University of Parana, Curitiba, Brazil Background: Rotigotine is the first non-ergot derived dopamine agonist administered via transdermal patch technology, indicated for use in early and advanced PD. The potential advantages of rotigotine include immediate effect onset, constant drug delivery, and ease of use, once-daily adhesive patch. Rotigotine demonstrated efficacy and safety as monotherapy in PD to reduce duration of OFF periods. Rotigotine has high affinity for dopamine D(2) and D(3) receptors. The most commonly reported adverse event are application-site reactions, somnolence and nausea. Druginduced nail abnormalities, particularly nail dyschromia, are wellknown complications related to several drugs, including zidovudine, cancer chemotherapies, retinoids, tetracycline and minocycline. The objective of this study is to present for the first time an unusual complication related to treatment of Parkinson’s disease (PD) with rotigotine transdermal patch.
Figure 1.
Figure 2. Conclusions: The close cause and effect relationship found in the case presented here demonstrates that rotigotine transdermal may be associated with nail dyschromia. Clinicians prescribing this drug should be aware of this reversible complication. 2.288 COMBINED ZOLPIDEM AND CARBIDOPA/LEVODOPA TREATMENT OF PROGRESSIVE SUPRANUCLEAR PALSY (PSP): A CASE REPORT WITH VIDEO DOCUMENTATION S. Chen1 , S. Juneja2 , S.L. Jaffe1 . 1 Neurology, 2 Medical School, Louisiana State University School of Medicine, Shreveport, LA, USA Introduction: PSP is characterized by ocular (supranuclear gaze palsies), motor (bradykinesia/akinesia, rigidity, postural impairment, extensor dystonia), and pseudobulbar (dysarthria, dysphagia) symptoms/signs in addition to frontal lobe/cognitive/personality impairment. Carbidopa/levodopa is the primary treatment medication although benefits are limited (striatal D2 receptor loss). In addition to dopaminergic and cholinergic circuitry, gabanergic circuitry is also affected in the PSP brain. A case of severe PSP was treated with zolpidem, a selective agonist of the benzodiazepine receptor (BZ1) on the GABA-A receptor complex, alpha subunit, and carbidopa/levodopa. Video documentation was obtained. Method: Case Report – A 63 year old man, end-stage/typical PSP, symptomatic for 4 years, with classical findings on brain MRI was treated with zolpidem IR, 5 mg, together with carbidopa/levodopa, 25/250, three times a day (7AM, Noon, and 5PM, i.e. q 5 hrs). Video documentation was obtained during baseline treatment with carbidopa/levodopa, and at 1 and 2 days after combination treatment. Results: Carbidopa/levodopa improved akinesia, limb rigidity, dysarthria and dysphagia. These benefits were augmented by adding zolpidem, and further immediate improvement (maximizing in 1 hour, lasting 5 hours) was observed in horizontal eye movement, facial expression, akinesia, limb and especially axial rigidity/extensor dystonia, resulting in the patient sitting, standing