Pharmacotherapy Overview of Parkinson's Disease and Related Disorders
O
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:
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=
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•
Non-specific symptoms: fatigue, depression
Non-specific symptoms: fatigue, depression
•
S
S
p
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m
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m
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:
:
•
Resting tremor, stiffness (rigidity) and increased muscle tone,
Resting tremor, stiffness (rigidity) and increased muscle tone,
postural impairments
postural impairments
•
Extent of movements is limited, ability to move is slown down
Extent of movements is limited, ability to move is slown down
•
Impairment of the movement initiation, akinesia (sudden inability
Impairment of the movement initiation, akinesia (sudden inability
to move)
to move)
•
Typical changes in walking, graphomotor skills and facial mimics
Typical changes in walking, graphomotor skills and facial mimics
•
Psychiatric symptoms: cognitive impairment
Psychiatric symptoms: cognitive impairment
•
Late-onset dyskinesia (night akinesia, morning stiffness, cramps)
Late-onset dyskinesia (night akinesia, morning stiffness, cramps)
•
https://www.youtube.com/watch?v=j86omOwx0Hk
https://www.youtube.com/watch?v=j86omOwx0Hk
•
D
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:
L
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D
D
O
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P
P
A
A
•
Metabolised by DOPA decarboxylase to DA in CNS
Metabolised by DOPA decarboxylase to DA in CNS
•
Used orally several times a day
Used orally several times a day
•
A
A
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:
:
a
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)
)
M
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entacapone, tolcapone
entacapone, tolcapone
•
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carbidopa, benserazide
carbidopa, benserazide
•
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Used orally or by TTS
Used orally or by TTS
•
A
A
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:
:
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•
Ergot alkaloids derivatives
Ergot alkaloids derivatives
•
A
A
E
E
:
:
f
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b
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r
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N
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•
Lower risk of psychiatric AE, no fibrotic changes
Lower risk of psychiatric AE, no fibrotic changes
A
A
d
d
j
j
u
u
v
v
a
a
n
n
t
t
t
t
h
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e
r
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a
a
p
p
y
y
o
o
f
f
P
P
a
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r
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k
k
i
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n
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s
s
o
o
n
n
‘
‘
s
s
d
d
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a
a
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:
:
•
S
S
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–
–
M
M
A
A
O
O
B
B
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n
n
h
h
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b
b
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r
r
(
(
D
D
A
A
d
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a
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d
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t
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o
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n
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e
n
n
z
z
y
y
m
m
e
e
)
)
•
Anticholinergics:
Anticholinergics:
•
Relative excess of ACh → worsening of dyskinesia
Relative excess of ACh → worsening of dyskinesia
•
Only for short-term use
Only for short-term use
•
C
C
o
o
n
n
t
t
r
r
a
a
i
i
n
n
d
d
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c
c
a
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n
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:
:
e
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d
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r
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,
p
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a
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d
d
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f
f
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c
c
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•
A
A
E
E
:
:
a
a
n
n
t
t
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c
c
h
h
o
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l
l
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n
n
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r
r
g
g
i
i
c
c
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f
f
f
f
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c
c
t
t
s
s
–
–
3
3
r
r
d
d
l
l
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c
c
t
t
u
u
r
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•
A
A
m
m
a
a
n
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a
a
d
d
i
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e
e
–
–
i
i
.
.
v
v
.
.
i
i
n
n
f
f
u
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s
s
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n
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n
s
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v
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e
r
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a
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c
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d
d
y
y
s
s
k
k
i
i
n
n
e
e
s
s
i
i
a
a
•
Biperiden, procyclidine – used orally
Biperiden, procyclidine – used orally
•
Abnormal reaction of dopaminergic system
Abnormal reaction of dopaminergic system
•
Imbalance between DA and ACh in CNS
Imbalance between DA and ACh in CNS
•
Up-regulation of D receptors in basal ganglia
Up-regulation of D receptors in basal ganglia
•
D
D
y
y
s
s
t
t
o
o
n
n
i
i
a
a
,
,
a
a
k
k
a
a
t
t
h
h
i
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s
s
i
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a
a
,
,
f
f
a
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c
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c
c
h
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r
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a
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c
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m
m
o
o
v
v
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m
m
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n
n
t
t
s
s
•
T
T
a
a
r
r
d
d
i
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v
v
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d
d
y
y
s
s
k
k
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,
p
p
a
a
r
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k
k
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n
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s
s
o
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n
n
i
i
s
s
m
m
a)
T
T
y
y
p
p
i
i
c
c
a
a
l
l
(
(
c
c
l
l
a
a
s
s
s
s
i
i
c
c
a
a
l
l
)
)
a
a
n
n
t
t
i
i
p
p
s
s
y
y
c
c
h
h
o
o
t
t
i
i
c
c
s
s
–
–
c
c
h
h
l
l
o
o
r
r
p
p
r
r
o
o
m
m
a
a
z
z
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e
e
,
,
l
l
e
e
v
v
o
o
p
p
r
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o
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m
m
a
a
z
z
i
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,
,
p
p
r
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o
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c
c
h
h
l
l
o
o
r
r
p
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e
r
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a
a
z
z
i
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n
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e
,
,
p
p
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r
r
f
f
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n
n
a
a
z
z
i
i
n
n
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e
,
,
h
h
a
a
l
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o
o
p
p
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e
r
r
i
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d
d
o
o
l
l
…
…
•
Approx. 20% pacients !
Approx. 20% pacients !
b)
H
H
1
1
antihistamines of 1
antihistamines of 1
st
st
generation – thiethylperazine, prometazine
generation – thiethylperazine, prometazine
c)
Prokinetic agents – metoklopramid
Prokinetic agents – metoklopramid
d)
Older antihypertensive – reserpine,
Older antihypertensive – reserpine,
α-
α-
methyldopa
methyldopa
e)
Antivertigo agents – cinnarizine, flunarizine
Antivertigo agents – cinnarizine, flunarizine
f)
Antiepileptics – phenytoin, carbamazepine
Antiepileptics – phenytoin, carbamazepine
g)
Antidepressants – tricyclic AD, trazodone
Antidepressants – tricyclic AD, trazodone
h)
Centrally active muscle relaxant baclofen
Centrally active muscle relaxant baclofen
P
P
h
h
a
a
r
r
m
m
a
a
c
c
o
o
t
t
h
h
e
e
r
r
a
a
p
p
y
y
:
:
•
S
S
w
w
i
i
t
t
c
c
h
h
t
t
o
o
s
s
a
a
f
f
e
e
r
r
d
d
r
r
u
u
g
g
(
(
s
s
a
a
f
f
e
e
r
r
a
a
n
n
t
t
i
i
p
p
s
s
y
y
c
c
h
h
o
o
t
t
i
i
c
c
e
e
t
t
c
c
.
.
)
)
+
+
•
D
D
y
y
s
s
t
t
o
o
n
n
i
i
a
a
,
,
a
a
k
k
a
a
t
t
h
h
i
i
s
s
i
i
a
a
→
→
i
i
.
.
v
v
.
.
,
,
p
p
.
.
o
o
.
.
a
a
n
n
t
t
i
i
c
c
h
h
o
o
l
l
i
i
n
n
e
e
r
r
g
g
i
i
c
c
s
s
•
T
T
a
a
r
r
d
d
i
i
v
v
e
e
d
d
y
y
s
s
k
k
i
i
n
n
e
e
s
s
i
i
a
a
→
→
s
s
o
o
m
m
e
e
t
t
i
i
m
m
e
e
s
s
i
i
.
.
m
m
.
.
b
b
o
o
t
t
u
u
l
l
i
i
n
n
u
u
m
m
t
t
o
o
x
x
i
i
n
n
•
P
P
a
a
r
r
k
k
i
i
n
n
s
s
o
o
n
n
i
i
s
s
m
m
→
→
a
a
n
n
t
t
i
i
p
p
a
a
r
r
k
k
i
i
n
n
s
s
o
o
n
n
a
a
g
g
e
e
n
n
t
t
s
s
•
B
B
e
e
n
n
z
z
o
o
d
d
i
i
a
a
z
z
e
e
p
p
i
i
n
n
e
e
s
s
p
p
.
.
o
o
.
.
,
,
i
i
.
.
v
v
.
.
–
–
s
s
e
e
d
d
a
a
t
t
i
i
o
o
n
n
,
,
m
m
u
u
s
s
c
c
l
l
e
e
r
r
e
e
l
l
a
a
x
x
a
a
t
t
i
i
o
o
n
n
•
Enhace GABAergic transmission
Enhace GABAergic transmission
= unintentional, involuntary, quick, irregular movements
= unintentional, involuntary, quick, irregular movements
https://www.youtube.com/watch?v=OveGZdZ_sVs
https://www.youtube.com/watch?v=OveGZdZ_sVs
Causes:
Causes:
•
Huntington‘s chorea
Huntington‘s chorea
(hereditary neurodegenerative disease)
(hereditary neurodegenerative disease)
•
vascular chorea
vascular chorea
(ischemia in basal ganglia)
(ischemia in basal ganglia)
•
chorea minor
chorea minor
(autoimmune disease)
(autoimmune disease)
P
P
h
h
a
a
r
r
m
m
a
a
c
c
o
o
t
t
h
h
e
e
r
r
a
a
p
p
y
y
:
:
•
A
A
n
n
t
t
i
i
p
p
s
s
y
y
c
c
h
h
o
o
t
t
i
i
c
c
s
s
–
–
t
t
y
y
p
p
i
i
c
c
a
a
l
l
(
(
h
h
a
a
l
l
o
o
p
p
e
e
r
r
i
i
d
d
o
o
l
l
)
)
,
,
o
o
r
r
a
a
t
t
y
y
p
p
i
i
c
c
a
a
l
l
(
(
r
r
i
i
s
s
p
p
e
e
r
r
i
i
d
d
o
o
n
n
e
e
)
)
•
Risk of additional extrapyramidal reactions
Risk of additional extrapyramidal reactions
•
Reserpine, tetrabenazine – ↓ levels of DA in CNS
Reserpine, tetrabenazine – ↓ levels of DA in CNS
•
Risk of additional extrapyramidal reactions, depression,
Risk of additional extrapyramidal reactions, depression,
hypotension
hypotension
•
B
B
e
e
n
n
z
z
o
o
d
d
i
i
a
a
z
z
e
e
p
p
i
i
n
n
e
e
s
s
(
(
c
c
l
l
o
o
n
n
a
a
z
z
e
e
p
p
a
a
m
m
)
)
•
Amantadine
Amantadine
Caused by damages of motor neurons:
Caused by damages of motor neurons:
a)
a)
peripheral motor neurons
peripheral motor neurons
– ↓ muscle tone, strenght,
– ↓ muscle tone, strenght,
progressive atrophy of skeletal muscles, long bones
progressive atrophy of skeletal muscles, long bones
and skin
and skin
•
poliomyelitis anterior acuta
poliomyelitis anterior acuta
•
Charcot-Marie-Tooth disease
Charcot-Marie-Tooth disease
•
myasthenia gravis
myasthenia gravis
b)
b)
central motor neurons
central motor neurons
– ↑ muscle tone, muscle contractures,
– ↑ muscle tone, muscle contractures,
limited ability of joints to move, joint dislocations, muscle
limited ability of joints to move, joint dislocations, muscle
hypertrophy → atrophy, deformities of long bones
hypertrophy → atrophy, deformities of long bones
•
Cerebral palsy (CP)
Cerebral palsy (CP)
P
P
h
h
a
a
r
r
m
m
a
a
c
c
o
o
t
t
h
h
e
e
r
r
a
a
p
p
y
y
i
i
s
s
a
a
n
n
a
a
d
d
j
j
u
u
v
v
a
a
n
n
t
t
t
t
r
r
e
e
a
a
t
t
m
m
e
e
n
n
t
t
–
–
i
i
m
m
p
p
r
r
o
o
v
v
e
e
s
s
t
t
h
h
e
e
r
r
e
e
s
s
u
u
l
l
t
t
s
s
o
o
f
f
p
p
h
h
y
y
s
s
i
i
o
o
t
t
h
h
e
e
r
r
a
a
p
p
y
y
,
,
o
o
r
r
e
e
n
n
a
a
b
b
l
l
e
e
s
s
i
i
t
t
t
t
o
o
b
b
e
e
c
c
a
a
r
r
r
r
i
i
e
e
d
d
o
o
u
u
t
t
!
!
B
B
o
o
t
t
u
u
l
l
i
i
n
n
u
u
m
m
t
t
o
o
x
x
i
i
n
n
A
A
•
Polypeptide from
Polypeptide from
Clostridium botulinum
Clostridium botulinum
•
Injected i.m. into the spastic muscles
Injected i.m. into the spastic muscles
•
C
C
a
a
u
u
s
s
e
e
s
s
i
i
r
r
r
r
e
e
v
v
e
e
r
r
s
s
i
i
b
b
l
l
e
e
i
i
n
n
h
h
i
i
b
b
i
i
t
t
i
i
o
o
n
n
o
o
f
f
A
A
C
C
h
h
r
r
e
e
l
l
e
e
a
a
s
s
e
e
i
i
n
n
N
N
J
J
s
s
–
–
p
p
e
e
r
r
i
i
p
p
h
h
e
e
r
r
a
a
l
l
l
l
y
y
a
a
c
c
t
t
i
i
v
v
e
e
m
m
u
u
s
s
c
c
l
l
e
e
r
r
e
e
l
l
a
a
x
x
a
a
n
n
t
t
(
(
p
p
r
r
e
e
s
s
y
y
n
n
a
a
p
p
t
t
i
i
c
c
a
a
l
l
l
l
y
y
a
a
c
c
t
t
i
i
n
n
g
g
)
)
•
A
A
l
l
l
l
e
e
v
v
i
i
a
a
t
t
e
e
p
p
a
a
i
i
n
n
a
a
s
s
s
s
o
o
c
c
i
i
a
a
t
t
e
e
d
d
w
w
i
i
t
t
h
h
s
s
p
p
a
a
s
s
m
m
s
s
•
E
E
n
n
a
a
b
b
l
l
e
e
s
s
m
m
u
u
s
s
c
c
l
l
e
e
g
g
r
r
o
o
w
w
t
t
h
h
–
–
b
b
e
e
n
n
e
e
f
f
i
i
t
t
f
f
o
o
r
r
c
c
h
h
i
i
l
l
d
d
r
r
e
e
n
n
w
w
i
i
t
t
h
h
C
C
P
P
•
Administered repeatedly, but sometimes
Administered repeatedly, but sometimes
1 inj. can act even for 12 months
1 inj. can act even for 12 months
•
Reinnervation of muscles – new NJs
Reinnervation of muscles – new NJs
are created in the muscle → spasms reoccur
are created in the muscle → spasms reoccur
•
I
I
m
m
p
p
r
r
o
o
v
v
e
e
s
s
p
p
h
h
y
y
s
s
i
i
o
o
t
t
h
h
e
e
r
r
a
a
p
p
y
y
e
e
f
f
f
f
e
e
c
c
t
t
s
s
!
!
•
Spasticity of larger areas → centrally acting muscle relaxants
Spasticity of larger areas → centrally acting muscle relaxants
B
B
A
A
C
C
L
L
O
O
F
F
E
E
N
N
•
G
G
A
A
B
B
A
A
B
B
a
a
g
g
o
o
n
n
i
i
s
s
t
t
–
–
e
e
n
n
h
h
a
a
n
n
c
c
e
e
s
s
G
G
A
A
B
B
A
A
e
e
r
r
g
g
i
i
c
c
t
t
r
r
a
a
n
n
s
s
m
m
i
i
s
s
s
s
i
i
o
o
n
n
=
=
i
i
n
n
h
h
i
i
b
b
i
i
t
t
s
s
r
r
e
e
l
l
e
e
a
a
s
s
e
e
o
o
f
f
e
e
x
x
c
c
i
i
t
t
a
a
t
t
o
o
r
r
y
y
A
A
A
A
(
(
g
g
l
l
u
u
t
t
a
a
m
m
a
a
t
t
e
e
,
,
a
a
s
s
p
p
a
a
r
r
t
t
a
a
t
t
e
e
)
)
•
A
A
E
E
:
:
d
d
r
r
o
o
w
w
s
s
i
i
n
n
e
e
s
s
s
s
,
,
c
c
o
o
n
n
f
f
u
u
s
s
i
i
o
o
n
n
,
,
h
h
y
y
p
p
o
o
t
t
e
e
n
n
s
s
i
i
o
o
n
n
,
,
m
m
u
u
s
s
c
c
l
l
e
e
w
w
e
e
a
a
k
k
n
n
e
e
s
s
s
s
•
P
P
r
r
o
o
g
g
r
r
e
e
s
s
s
s
i
i
v
v
e
e
t
t
o
o
l
l
e
e
r
r
a
a
n
n
c
c
e
e
–
–
n
n
e
e
e
e
d
d
f
f
o
o
r
r
h
h
i
i
g
g
h
h
e
e
r
r
d
d
o
o
s
s
e
e
s
s
•
I
I
n
n
t
t
r
r
a
a
t
t
h
h
e
e
c
c
a
a
l
l
a
a
d
d
m
m
i
i
n
n
i
i
s
s
t
t
r
r
a
a
t
t
i
i
o
o
n
n
–
–
s
s
.
.
c
c
.
.
p
p
u
u
m
m
p
p
w
w
i
i
t
t
h
h
c
c
a
a
t
t
h
h
e
e
t
t
e
e
r
r
i
i
n
n
s
s
e
e
r
r
t
t
e
e
d
d
i
i
n
n
t
t
o
o
s
s
u
u
b
b
a
a
r
r
a
a
c
c
h
h
n
n
o
o
i
i
d
d
e
e
a
a
l
l
s
s
p
p
a
a
c
c
e
e
=
=
l
l
o
o
w
w
e
e
r
r
d
d
o
o
s
s
e
e
s
s
α
α
2
2
R
R
E
E
C
C
E
E
P
P
T
T
O
O
R
R
A
A
G
G
O
O
N
N
I
I
S
S
T
T
S
S
•
Activation lead to decrease of neurotransmitter levels in CNS –
Activation lead to decrease of neurotransmitter levels in CNS –
in spinal cord activation inhibits release of excitatory AA
in spinal cord activation inhibits release of excitatory AA
•
A
A
E
E
:
:
s
s
e
e
d
d
a
a
t
t
i
i
o
o
n
n
,
,
x
x
e
e
r
r
o
o
s
s
t
t
o
o
m
m
i
i
a
a
,
,
b
b
r
r
a
a
d
d
y
y
c
c
a
a
r
r
d
d
i
i
a
a
,
,
h
h
y
y
p
p
o
o
t
t
e
e
n
n
s
s
i
i
o
o
n
n
•
t
t
i
i
z
z
a
a
n
n
i
i
d
d
i
i
n
n
e
e
,
,
c
c
l
l
o
o
n
n
i
i
d
d
i
i
n
n
e
e
B
B
E
E
N
N
Z
Z
O
O
D
D
I
I
A
A
Z
Z
E
E
P
P
I
I
N
N
E
E
S
S
–
–
c
c
l
l
o
o
n
n
a
a
z
z
e
e
p
p
a
a
m
m
,
,
t
t
e
e
t
t
r
r
a
a
z
z
e
e
p
p
a
a
m
m
,
,
d
d
i
i
a
a
z
z
e
e
p
p
a
a
m
m
Other drugs used in spastic disorders:
Other drugs used in spastic disorders:
•
d
d
a
a
n
n
t
t
r
r
o
o
l
l
e
e
n
n
e
e
•
g
g
a
a
b
b
a
a
p
p
e
e
n
n
t
t
i
i
n
n
,
,
l
l
a
a
m
m
o
o
t
t
r
r
i
i
g
g
i
i
n
n
e
e
–
–
a
a
n
n
t
t
i
i
e
e
p
p
i
i
l
l
e
e
p
p
t
t
i
i
c
c
s
s
(
(
G
G
A
A
B
B
A
A
e
e
r
r
g
g
i
i
c
c
M
M
o
o
A
A
)
)
•
r
r
i
i
l
l
u
u
z
z
o
o
l
l
e
e
–
–
a
a
m
m
y
y
o
o
t
t
r
r
o
o
p
p
h
h
i
i
c
c
l
l
a
a
t
t
e
e
r
r
a
a
l
l
s
s
c
c
l
l
e
e
r
r
o
o
s
s
i
i
s
s
C
C
a
a
n
n
n
n
a
a
b
b
i
i
n
n
o
o
i
i
d
d
s
s
•
M
M
i
i
x
x
t
t
u
u
r
r
e
e
o
o
f
f
T
T
H
H
C
C
a
a
n
n
d
d
c
c
a
a
n
n
n
n
a
a
b
b
i
i
d
d
i
i
o
o
l
l
(
(
o
o
r
r
a
a
l
l
s
s
p
p
r
r
a
a
y
y
)
)
•
A
A
g
g
o
o
n
n
i
i
s
s
t
t
s
s
o
o
f
f
C
C
B
B
1
1
a
a
n
n
d
d
C
C
B
B
2
2
r
r
e
e
c
c
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p
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d
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c
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t
t
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t
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r
r
y
y
A
A
A
A
•
Good therapeutical outcome in 30‒40% patients
Good therapeutical outcome in 30‒40% patients
•
A
A
E
E
:
:
p
p
s
s
y
y
c
c
h
h
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r
r
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f
f
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d
d
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w
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t
c
c
.
.
•
Y
Y
o
o
u
u
n
n
g
g
p
p
a
a
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t
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i
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e
n
n
t
t
s
s
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n
n
c
c
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k
k
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f
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c
c
h
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p
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c
h
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v
v
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l
l
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p
p
m
m
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n
n
t
t
!
!
•
A
A
u
u
t
t
o
o
i
i
m
m
m
m
u
u
n
n
e
e
d
d
i
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s
s
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a
a
s
s
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a
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u
t
t
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o
a
a
n
n
t
t
i
i
b
b
o
o
d
d
i
i
e
e
s
s
a
a
g
g
a
a
n
n
i
i
s
s
t
t
N
N
M
M
r
r
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e
c
c
e
e
p
p
t
t
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o
r
r
s
s
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f
f
N
N
J
J
s
s
(
(
w
w
o
o
m
m
e
e
n
n
>
>
m
m
e
e
n
n
)
)
•
Fluctuating muscle weakness, patient get tired easily,
Fluctuating muscle weakness, patient get tired easily,
worsening in afternoon and evening and after muscle strain
worsening in afternoon and evening and after muscle strain
•
1
1
s
s
t
t
s
s
y
y
m
m
p
p
t
t
o
o
m
m
s
s
:
:
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c
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l
a
a
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m
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p
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s
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•
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P
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:
:
f
f
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m
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c
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f
f
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s
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s
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.
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)
•
S
S
e
e
v
v
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e
r
r
e
e
p
p
r
r
o
o
g
g
r
r
e
e
s
s
s
s
i
i
o
o
n
n
:
:
m
m
y
y
a
a
s
s
t
t
h
h
e
e
n
n
i
i
c
c
c
c
r
r
i
i
s
s
i
i
s
s
–
–
r
r
e
e
s
s
p
p
i
i
r
r
a
a
t
t
o
o
r
r
y
y
m
m
u
u
s
s
c
c
l
l
e
e
s
s
•
Drugs inducing MG: interferon
Drugs inducing MG: interferon
α
α
•
Drugs worsening MG: aminoglycosides, quinidine, quinine,
Drugs worsening MG: aminoglycosides, quinidine, quinine,
chloroquine, i.v. Mg
chloroquine, i.v. Mg
2+
2+
•
C
C
h
h
o
o
l
l
i
i
n
n
o
o
m
m
i
i
m
m
e
e
t
t
i
i
c
c
s
s
–
–
a
a
c
c
e
e
t
t
y
y
l
l
c
c
h
h
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o
l
l
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n
n
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s
s
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r
r
a
a
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n
h
h
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b
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t
t
o
o
r
r
s
s
=
=
↑
↑
l
l
e
e
v
v
e
e
l
l
s
s
o
o
f
f
A
A
C
C
h
h
v
v
s
s
y
y
n
n
a
a
p
p
t
t
i
i
c
c
c
c
l
l
e
e
f
f
t
t
s
s
a
a
n
n
d
d
N
N
J
J
s
s
•
p
p
y
y
r
r
i
i
d
d
o
o
s
s
t
t
i
i
g
g
m
m
i
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n
n
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e
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–
p
p
.
.
o
o
.
.
s
s
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e
v
v
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r
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a
l
l
t
t
i
i
m
m
e
e
s
s
a
a
d
d
a
a
y
y
•
neostigmine – short-term acting, before muscle strain
neostigmine – short-term acting, before muscle strain
•
ambedonium – N
ambedonium – N
+
+
, no central effect
, no central effect
•
A
A
E
E
:
:
a
a
c
c
t
t
i
i
v
v
a
a
t
t
i
i
o
o
n
n
o
o
f
f
A
A
C
C
h
h
r
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e
c
c
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p
p
t
t
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r
r
s
s
=
=
c
c
h
h
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o
l
l
i
i
n
n
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r
g
g
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t
t
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s
:
:
a
a
)
)
m
m
u
u
s
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c
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a
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n
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(
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v
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a
t
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m
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a
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b
r
r
o
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s
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,
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r
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c
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o
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t
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(
(
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f
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s
s
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l
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a
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c
c
c
u
u
m
m
u
u
l
l
a
a
t
t
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i
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n
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→
→
c
c
h
h
o
o
l
l
i
i
n
n
e
e
r
r
g
g
i
i
c
c
c
c
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s
s
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d
e
e
p
p
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o
l
l
a
a
r
r
i
i
z
z
a
a
t
t
i
i
o
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n
n
b
b
l
l
o
o
c
c
k
k
a
a
d
d
e
e
o
o
f
f
A
A
N
N
S
S
g
g
a
a
n
n
g
g
l
l
i
i
a
a
a
a
n
n
d
d
N
N
J
J
s
s
•
muscle weakness, potentially life-threatening
muscle weakness, potentially life-threatening
•
therapy: mechanical ventilation + i.v. atropine
therapy: mechanical ventilation + i.v. atropine
•
T
T
h
h
e
e
c
c
a
a
u
u
s
s
e
e
i
i
s
s
a
a
u
u
t
t
o
o
i
i
m
m
m
m
u
u
n
n
i
i
t
t
y
y
→
→
i
i
m
m
m
m
u
u
n
n
o
o
s
s
u
u
p
p
p
p
r
r
e
e
s
s
s
s
i
i
v
v
e
e
s
s
•
Decrease number of B
Decrease number of B
-
-
cells, which produce antibodies
cells, which produce antibodies
•
A
A
E
E
:
:
n
n
o
o
n
n
-
-
s
s
p
p
e
e
c
c
i
i
f
f
i
i
c
c
e
e
f
f
f
f
e
e
c
c
t
t
=
=
s
s
u
u
p
p
p
p
r
r
e
e
s
s
s
s
i
i
o
o
n
n
o
o
f
f
o
o
v
v
e
e
r
r
a
a
l
l
l
l
i
i
m
m
m
m
u
u
n
n
e
e
r
r
e
e
a
a
c
c
t
t
i
i
o
o
n
n
s
s
–
–
↑
↑
i
i
n
n
f
f
e
e
c
c
t
t
i
i
o
o
n
n
s
s
,
,
r
r
i
i
s
s
k
k
o
o
f
f
s
s
e
e
p
p
s
s
i
i
s
s
,
,
r
r
i
i
s
s
k
k
o
o
f
f
c
c
a
a
n
n
c
c
e
e
r
r
•
G
G
l
l
u
u
c
c
o
o
c
c
o
o
r
r
t
t
i
i
c
c
o
o
i
i
d
d
s
s
(
(
p
p
r
r
e
e
d
d
n
n
i
i
s
s
o
o
n
n
e
e
,
,
p
p
r
r
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e
d
d
n
n
i
i
s
s
o
o
l
l
o
o
n
n
e
e
,
,
m
m
e
e
t
t
h
h
y
y
l
l
p
p
r
r
e
e
d
d
n
n
i
i
s
s
o
o
l
l
o
o
n
n
e
e
)
)
•
T
T
i
i
t
t
r
r
a
a
t
t
i
i
o
o
n
n
d
d
o
o
s
s
e
e
,
,
t
t
h
h
e
e
l
l
o
o
w
w
e
e
s
s
t
t
e
e
f
f
f
f
i
i
c
c
i
i
e
e
n
n
t
t
d
d
o
o
s
s
e
e
i
i
s
s
u
u
s
s
e
e
d
d
•
L
L
o
o
n
n
g
g
-
-
t
t
e
e
r
r
m
m
o
o
r
r
a
a
l
l
t
t
h
h
e
e
r
r
a
a
p
p
y
y
w
w
i
i
t
t
h
h
t
t
y
y
p
p
i
i
c
c
a
a
l
l
A
A
E
E
(
(
s
s
t
t
o
o
m
m
a
a
c
c
h
h
,
,
a
a
d
d
i
i
p
p
o
o
s
s
e
e
t
t
i
i
s
s
s
s
u
u
e
e
,
,
d
d
i
i
a
a
b
b
e
e
t
t
e
e
s
s
,
,
b
b
o
o
n
n
e
e
s
s
t
t
r
r
u
u
c
c
t
t
u
u
r
r
e
e
…
…
)
)
•
A
A
z
z
a
a
t
t
h
h
i
i
o
o
p
p
r
r
i
i
n
n
e
e
–
–
s
s
t
t
o
o
p
p
s
s
p
p
r
r
o
o
l
l
i
i
f
f
e
e
r
r
a
a
t
t
i
i
o
o
n
n
o
o
f
f
l
l
y
y
m
m
p
p
h
h
o
o
c
c
y
y
t
t
e
e
s
s
•
Combination with corticoids – enables lower doses
Combination with corticoids – enables lower doses
•
Other immunosupress
Other immunosupress
ives
ives
: cyclosporin, mycophenolate,
: cyclosporin, mycophenolate,
methotrexate, tacrolimus
methotrexate, tacrolimus
•
D
D
i
i
s
s
e
e
a
a
s
s
e
e
o
o
f
f
t
t
h
h
e
e
i
i
n
n
n
n
e
e
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p
p
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•
Accumulation of endolymph + distended endolymphatic space
Accumulation of endolymph + distended endolymphatic space
•
A
A
c
c
u
u
t
t
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a
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k
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Dizziness (vertigo), nystagmus, tinnitus, hearing loss…
Dizziness (vertigo), nystagmus, tinnitus, hearing loss…
B
B
E
E
T
T
A
A
H
H
I
I
S
S
T
T
I
I
N
N
E
E
•
H
H
3
3
receptor antagonist
receptor antagonist
•
CNS, receptors of negative feedback
CNS, receptors of negative feedback
•
Regulate histaminergic transmission
Regulate histaminergic transmission
•
Antagonism = ↑ release of histamine
Antagonism = ↑ release of histamine
•
Vasodilation in the inner ear – better microcirculation
Vasodilation in the inner ear – better microcirculation
•
Long-term use (lifelong), orally
Long-term use (lifelong), orally
C
C
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n
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Antivertigo and prophylactic effect
Antivertigo and prophylactic effect
•
Used orally
Used orally
C
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b
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•
Improve circulation in CNS
Improve circulation in CNS
•
Increase erythrocytes deformability, reduce blood viscosity
Increase erythrocytes deformability, reduce blood viscosity
•
Mild antitrombotic, antiinflammatory and antioxidative effect
Mild antitrombotic, antiinflammatory and antioxidative effect
•
Used orally, i.v. in acute cases
Used orally, i.v. in acute cases
•
S
S
t
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a
a
n
n
d
d
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G
G
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V
V
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P
P
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n
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x
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x
x
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s
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•
Glucocorticoids, diuretics – antiedema effects
Glucocorticoids, diuretics – antiedema effects
•
Acute attack of Ménière‘s disease – nausea, vomiting,
Acute attack of Ménière‘s disease – nausea, vomiting,
dizziness, hearing loss, tinnitus, feeling of the pressure
dizziness, hearing loss, tinnitus, feeling of the pressure
in the ear…
in the ear…
A
A
n
n
t
t
i
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m
m
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cross BBB, central effects
cross BBB, central effects
•
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embramine, moxastine, dimenhydrinate…
embramine, moxastine, dimenhydrinate…
•
A
A
E
E
:
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Overview of pharmacological treatment options for Parkinson's disease and related conditions like choreatic dyskinesias, spastic disorders, and myasthenia gravis. Describes the degenerative process of Parkinson's disease, its symptoms, and the pharmacological interventions targeting dopamine deficits through medications like levodopa and dopamine receptor agonists. Also covers adjuvant therapies such as MAO-B inhibitors and anticholinergics for Parkinson's disease management.
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Special Chapters from Neurologic Pharmacotherapy
Overview of pharmacotherapy of: Parkinson s disease and parkinsonism choreatic dyskinesias spastic disorders myasthenia gravis M ni re s disease
Parkinsons Disease Degenerative disease of CNS: dying of dopaminergic neurons = dopamine deficit Non-specific symptoms: fatigue, depression Specific symptoms: Resting tremor, stiffness (rigidity) and increased muscle tone, postural impairments Extent of movements is limited, ability to move is slown down Impairment of the movement initiation, akinesia (sudden inability to move) Typical changes in walking, graphomotor skills and facial mimics Psychiatric symptoms: cognitive impairment Late-onset dyskinesia (night akinesia, morning stiffness, cramps) https://www.youtube.com/watch?v=j86omOwx0Hk
Pharmacotherapy of PD Dopamine (DA) deficit DA precursor: LEVODOPA Metabolised by DOPA decarboxylase to DA in CNS Used orally several times a day AE: a) Metabolism to DA in periphery = vomiting, diarrhea, gastric ulcers, hypertension, tachycardia b) DA excess = hallucinations, agression, psychosis (rarely) + COMT inhibitors (catechol-O-methyl transferase) entacapone, tolcapone + Peripheral DOPA decarboxylase inhibitors carbidopa, benserazide Wearing-off effect quick subsiding of the effect
Pharmacotherapy of PD Dopamine (DA) deficit D receptors agonists Used orally or by TTS AE: drowsiness, irresistible falling asleep ( sleep attacks ) a) Ergoline derivatives bromocriptine,pergolide, dihydroergocriptine Ergot alkaloids derivatives AE: fibrotic changes in lungs, heart valves + increased risk of psychiatric AE (psychotic symptoms) b) Non-ergoline drugs ropinirole, pramipexole, rotigotine Lower risk of psychiatric AE, no fibrotic changes
Pharmacotherapy of PD Adjuvant therapy of Parkinson s disease: Selegiline MAO B inhibitor (DA degradation enzyme) Anticholinergics: Relative excess of ACh worsening of dyskinesia Only for short-term use Contraindication: elderly, patients with cognitive deficit AE: anticholinergic effects 3rd lecture Amantadine i.v. infusion in severe acute dyskinesia Biperiden, procyclidine used orally
Drug-induced Extrapyramidal Reactions Abnormal reaction of dopaminergic system Imbalance between DA and ACh in CNS Up-regulation of D receptors in basal ganglia Dystonia, akathisia, facial choreatic movements Tardive dyskinesia, parkinsonism a) Typical (classical) antipsychotics chlorpromazine, levopromazine, prochlorperazine, perfenazine, haloperidol Approx. 20% pacients ! H1 antihistamines of 1st generation thiethylperazine, prometazine Prokinetic agents metoklopramid Older antihypertensive reserpine, -methyldopa Antivertigo agents cinnarizine, flunarizine Antiepileptics phenytoin, carbamazepine Antidepressants tricyclic AD, trazodone Centrally active muscle relaxant baclofen b) c) d) e) f) g) h)
Drug-induced Extrapyramidal Reactions Pharmacotherapy: Switch to safer drug (safer antipsychotic etc.) + Dystonia, akathisia i.v., p.o. anticholinergics Tardive dyskinesia sometimes i.m. botulinum toxin Parkinsonism antiparkinson agents Benzodiazepines p.o., i.v. sedation, muscle relaxation Enhace GABAergic transmission
Choreatic Dyskinesia = unintentional, involuntary, quick, irregular movements https://www.youtube.com/watch?v=OveGZdZ_sVs Causes: Huntington s chorea (hereditary neurodegenerative disease) vascular chorea (ischemia in basal ganglia) chorea minor (autoimmune disease) Pharmacotherapy: Antipsychotics typical (haloperidol), or atypical (risperidone) Risk of additional extrapyramidal reactions Reserpine, tetrabenazine levels of DA in CNS Risk of additional extrapyramidal reactions, depression, hypotension Benzodiazepines(clonazepam) Amantadine
Spastic Disorders Caused by damages of motor neurons: a) peripheral motor neurons muscle tone, strenght, progressive atrophy of skeletal muscles, long bones and skin poliomyelitis anterior acuta Charcot-Marie-Tooth disease myasthenia gravis b) central motor neurons muscle tone, muscle contractures, limited ability of joints to move, joint dislocations, muscle hypertrophy atrophy, deformities of long bones Cerebral palsy (CP) Pharmacotherapy is an adjuvant treatment improves the results of physiotherapy, or enables it to be carried out!
Local Therapy Botulinum toxin A Polypeptide from Clostridium botulinum Injected i.m. into the spastic muscles Causes irreversible inhibition of ACh release in NJs peripherally active muscle relaxant (presynaptically acting) Alleviate pain associated with spasms Enables muscle growth benefit for children with CP Administered repeatedly, but sometimes 1 inj. can act even for 12 months Reinnervation of muscles new NJs are created in the muscle spasms reoccur Improves physiotherapy effects!
Systemic Therapy Spasticity of larger areas centrally acting muscle relaxants BACLOFEN GABAB agonist enhances GABAergic transmission = inhibits release of excitatory AA (glutamate, aspartate) AE: drowsiness, confusion, hypotension, muscle weakness Progressive tolerance need for higher doses Intrathecal administration s.c. pump with catheter inserted into subarachnoideal space = lower doses 2 RECEPTOR AGONISTS Activation lead to decrease of neurotransmitter levels in CNS in spinal cord activation inhibits release of excitatory AA AE: sedation, xerostomia, bradycardia, hypotension tizanidine, clonidine BENZODIAZEPINES clonazepam, tetrazepam, diazepam
Systemic Therapy Other drugs used in spastic disorders: dantrolene gabapentin, lamotrigine antiepileptics (GABAergic MoA) riluzole amyotrophic lateral sclerosis Cannabinoids Mixture of THC and cannabidiol (oral spray) Agonists of CB1and CB2 receptors, decrease releasing of excitatory AA Good therapeutical outcome in 30 40% patients AE: psychiatric (mood changes, depression, cognitive impairment, appetite changes etc.), GIT AE, off-balance, drowsiness etc. Young patients increased risk of schizophrenia or psychosis development !
Myasthenia gravis Autoimmune disease autoantibodies aganist NM receptors of NJs (women > men) Fluctuating muscle weakness, patient get tired easily, worsening in afternoon and evening and after muscle strain 1st symptoms: ocular muscles, ptosis Progression: facial muscles (facial weakness), head and neck muscles (difficulties with chewing, swallowing, speaking etc.) Severe progression: myasthenic crisis respiratory muscles Drugs inducing MG: interferon Drugs worsening MG: aminoglycosides, quinidine, quinine, chloroquine, i.v. Mg2+
Symptomatic Therapy of MG Cholinomimetics acetylcholine esterase inhibitors = levels of ACh v synaptic clefts and NJs pyridostigmine p.o. several times a day neostigmine short-term acting, before muscle strain ambedonium N+, no central effect AE: activation of ACh receptors = cholinergic effects: a) muscarinic(salivation, sweating, streaming eyes, miosis, blurred vision, nausea, diarrhea, abdominal cramps, bronchospasmus, confusion, restlessness ) b) nicotinic (fasciculations) c) accumulation cholinergic crisis = depolarization blockade muscle weakness, potentially life-threatening therapy: mechanical ventilation + i.v. atropine of ANS ganglia and NJs
Causal Therapy of MG The cause is autoimmunity immunosuppressives Decrease number of B-cells, which produce antibodies AE: non-specific effect = suppression of overall immune reactions infections, risk of sepsis, risk of cancer Glucocorticoids (prednisone, prednisolone, methylprednisolone) Titration dose, the lowest efficient dose is used Long-term oral therapy with typical AE (stomach, adipose tissue, diabetes, bone structure ) Azathioprine stops proliferation of lymphocytes Combination with corticoids enables lower doses Other immunosupressives: cyclosporin, mycophenolate, methotrexate, tacrolimus
Mnires Disease Disease of the inner ear endolymphatic hydrops Accumulation of endolymph + distended endolymphatic space Acute attack: microrupture of vestibular membrane between endolymphatic and perilymphatic space Dizziness (vertigo), nystagmus, tinnitus, hearing loss
Prophylactic Pharmacotherapy BETAHISTINE H3 receptor antagonist CNS, receptors of negative feedback Regulate histaminergic transmission Antagonism = release of histamine Vasodilation in the inner ear better microcirculation Long-term use (lifelong), orally CINNARIZINE H1 receptor antagonist + T-type Ca2+ channel blockator Antivertigo and prophylactic effect Used orally
Prophylactic Pharmacotherapy Cerebral vasodilators and hemorheologics Improve circulation in CNS Increase erythrocytes deformability, reduce blood viscosity Mild antitrombotic, antiinflammatory and antioxidative effect Used orally, i.v. in acute cases Standardized extract from Ginkgo biloba Vinpocetine Pentoxifylline Other drugs used for prophylaxis Glucocorticoids, diuretics antiedema effects
Antivertigo Drugs Acute attack of M ni re s disease nausea, vomiting, dizziness, hearing loss, tinnitus, feeling of the pressure in the ear Antiemetic/antivertigo drugs: H1 antihistamines of 1st generation cross BBB, central effects used also for the treatment of motion sickness embramine, moxastine, dimenhydrinate AE: drowsiness, attention (vigilance) deficit thiethylperazine D2 receptor antagonist (suppositories) cinnarizine + H1 antihistamines
