回复974楼 章华
回复974楼 章华
长期使用多巴类或者激动剂导致的精神症状,包括幻觉幻听,神志迷糊甚至出现精神错乱。
临床上有二个选择,一是选择减多巴类或者激动剂药量,但这样会减弱运动状况。二是不减药量,加精神科药物,但可能会出现其他副作用。
这是一个剂末并发精神症状(幻觉幻听、精神恍惚)的严重病例,方法只是添加唑尼沙胺,结果是令人满意的。一个月后精神状况稳定,运动状况改善。六个月后关期明显改善,生活自理可以参与家庭活动。十个月后日常可以骑自行车外出。
作者的观点,在这个病例的药物安排从而改善症状上,唑尼沙胺的添加就是Key(关键)。
CASE REPORT
Effectiveness of zonisamide in a patient with Parkinson’s disease and various levodopa-induced psychotic symptoms
Ichiro Yabe,1 Midori Ohta,2 Toshiaki Egashira,3 Kazunori Sato,1 Takahiro Kano,1 Makoto Hirotani,1 Yasuyuki Kunieda4 and Hidenao Sasaki1
1Department of Neurology, Hokkaido University Graduate School of Medicine, Sapporo, 2Rehabilitation Center, Departments of 3 Psychiatry, and 4 Internal Medicine, Wakkanai City Hospital, Wakkanai, Japan
Key words
dopamine agonists, levodopa, Parkinson’s disease, psychotic symptoms, zonisamide.
Accepted for publication 18 August 2014.
Correspondence
Ichiro Yabe
Department of Neurology, Hokkaido University Graduate School of Medicine, N15 W7, Kita-ku, Sapporo 060-8638, Japan. Email: yabe@med.hokudai.ac.jp
Abstract
Levodopa and dopamine agonists are useful as Parkinson’s disease medications. However, they often induce persistent psychotic symptoms and motor complica- tions, which make Parkinson’s disease treatment difficult. This is a case report of a patient with advanced Parkinson’s disease accompanied by exacerbation of motor symptoms and psychotic symptoms derived from prolonged use of conventional anti-Parkinson’s disease drugs, and in whom adjunctive therapy with a new anti- Parkinson’s disease drug, zonisamide, was shown to improve motor symptoms with no exacerbation of psychotic symptoms.
As medication for Parkinson’s disease (PD), levodopa (L-dopa) and dopamine agonists (DA) are used as the first- line of treatment for PD to activate dopamine neurons. How- ever, they often induce persistent psychotic symptoms includ- ing hallucinations and delusions. In addition, after long-term use of L-dopa, some patients experience motor complications, such as wearing-off and the on-off phenomenon, and involun- tary movement. In view of these facts, particular caution should be taken in the selection of drugs for the treatment of advanced PD. Zonisamide has been developed as a new anti- PD drug in Japan, and is considered to have various effects on PD. We report a case of an advanced PD patient with exacerbation of psychotic symptoms, and in whom adjunctive therapy with zonisamide proved to be effective.
Case report
A 47-year-old man was diagnosed with early-onset PD with a duration of 19 years. He reported no remarkable family histories.
An overview of clinical symptoms and the medication his- tory of the patient is presented in Figure 1. He noticed gait disturbance as a first symptom 19 years before zonisamide ini- tiation. Four years later, he was diagnosed with early-onset PD and started treatment. After receiving 7 years of treatment with L-dopa and DA, he manifested psychotic symptoms including hallucinations and delusions. Over the next 7 years, although he was treated with L-dopa/carbidopa, DA, anticho- linergics and antipsychotics, he was in and out of hospital nine times because of the manifestation and exacerbation of
psychotic symptoms (delusions, visual and auditory hallucina- tions, wandering, gambling problems, emotional disturbance), motor complications and gait disturbance.
He first visited the Department of Neurology, Wakkanai City Hospital in Wakkanai City, Japan, for treatment of his motor symptoms. His main symptoms were muscle rigidity of the left limbs, bradykinesia and freezing of gait, which were severe enough to require wheelchair confinement. No neuro- logical abnormalities were found in the cranial nerves, the cer- ebellum or the sensory system. Brain magnetic resonance imaging also showed no significant abnormalities.
Although the patient seemed to require an increased dose of anti-PD drugs, increasing the L-dopa dose was deemed inappropriate, as he was already suffering from psychotic symptoms. Instead we initiated adjunctive therapy with 25 mg/day zonisamide, in addition to 300 mg/day L-dopa and 4 mg/day ropinirole. As a result, a marked improvement was achieved in freezing gait, and he could walk by himself within a month of initiation of treatment with zonisamide. Meanwhile, his psychotic symptoms remained stable without aggravation. Six months later, the “off-time” periods were reduced. The patient’s daily life improved dramatically to the extent that he could engage in recreational activities with his family. Ten months after zonisamide initiation, improvement of gait freezing persisted, and he could go out on his bicycle during the day. His Unified Parkinson’s Disease Rating Scale scores markedly improved .