Efectividad y seguridad de Pramipexol comparado con Levodopa, Pergolida, Cabergolina, Ropinirole para el tratamiento del Síndrome de Piernas Inquietas / Effectiveness and safety of Pramipexole compared to Levodopa, Pergolide, Cabergoline, Ropinirole for the treatment of Restless Legs Syndrome

IIntroducción: el Síndrome de Piernas Inquietas (SPI) se define como un trastorno neurológico que afecta de un 5 % a un 15% de la población general, de causa desconocida, incurable y de evolución crónica, con afectación del sueño y la calidad de vida en alerta. Se cuenta con tratamientos para aliviar los síntomas que afectan la calidad de vida, una primera línea de tratamiento son los agonistas dopaminérgicos entre ellos la Levodopa, el Pramipexol y la Pergolida (8), (9), (10). Objetivo: evaluar la efectividad y seguridad del pramipexol, comparado con otros agonistas dopaminergicos para el tratamiento del Síndrome de Piernas Inquietas (RSL). Metodología: la evaluación fue realizada de acuerdo al protocolo definido previamente por el grupo desarrollador el cual incluye una revisión sistemática de la literatura en MEDLINE, EMBASE, LILACS, COCHRANE y Google para dar respuesta a la pregunta de investigación desarrollada bajo la estrategia PICOT en compañía de expertos técnicos y metodológicos. En el estudio de Scholz con el uso del pramipexol se observó una diferencia de medias de -5.16 [IC95% -6.87 a -3.45] comparado con placebo en la escala de síntomas IRLS (I²= 76%). Los agonistas dopaminérgicos comparados con el placebo produjeron una diferencia de medias en la reducción del PLMSI de −22.38 (IC95% −27.82 a −16.94) por hora de sueño (I² = 73%). El Pramipexol produjo contra placebo una diferencia de medias de -30.47 [IC9% -51.58 a -9.35] (I² = 85%) en el Cambio en el PLMSI (calidad del sueño, a favor de pramipexol. Los agonistas dopaminérgicos comparados con placebo reportaron una diferencia de medias de 0.4 [IC95% 0.33 a 0.47] a favor de los agonistas dopaminergicos respecto a la calidad del sueño autoreportada. En un análisis de subgrupos por medicamentos, el pramipexol produjo contra placebo un cambio en la calidad del sueño autoreportada con una diferencia de medias de 0.44 [IC: 0.33, 0.54], a favor de pramipexol. Los agonistas dopaminérgicos produjeron mejoría en la calidad de vida comparado contra placebo con una diferencia de medias de 0.34 [IC95% 0.23 a 0.44] (I²= 61%). En un análisis de subgrupos por medicamento, el pramipexol produjo mejoría en la calidad de vida comparado contra placebo con una diferencia estandarizada de medias de 0.30 [IC95% 0.13 a 0.47]. Los agonistas dopaminérgicos (cabergolina o pramipexol) comparados con levodopa produjeron un cambio en la línea de base del IRLS con una diferencia de medias de -5.25 [IC95% -8.40 a -2.10] (I²= 55%). En comparaciones indirectas dentro del estudio Ying Sun el pramipexol versus el ropirinole mostró una diferencia de medias en la escala de síntomas IRLS de -1.48 (IC95% -4.47 a 0.45) sin embargo esta diferencia no fue estadísticamente significativa. Respecto a la seguridad, los eventos adversos fueron más frecuentes en el grupo de pacientes que recibió agonistas dopaminérgicos comparado con los pacientes que recibieron placebo con un OR de 1.82 [IC95% 1.59 a 2.08]. Los retiros por eventos adversos fue superior en el grupo de agonistas dopaminergicos versus placebo, con un OR 1.82, (IC95% 1.35 a 2.45), diferencia estadísticamente significativa y mostró una heterogeneidad moderada (I² = 41%). Los retiros por eventos adversos fue superior en el grupo de agonistas dopaminergicos versus placebo, con un OR 1.82, (IC95% 1.35 a 2.45), diferencia estadísticamente significativa y mostró una heterogeneidad moderada (I² = 41%). En un análisis de subgrupos por medicamentos, se reportaron más retiros con pramipexol que con placebo con un OR de 1.11 [IC95% 0.66 a 1.87], esta diferencia no fue estadísticamente significativa con una heterogeneidad moderada (I²= 44%). Conclusiones: Efectividad: Los agonistas dopaminergicos, dentro de los cuales está incluido el pramipexol, son más efectivos que el placebo en el tratamiento de las personas con RLS para los desenlaces de escala de síntomas IRLS, la reducción del PLMSI , la calidad de sueño autoreportada y calidad de vida. En un análisis por subgrupos dentro de la comparación entre agonistas dopaminergicos y el placebo, el pramipexol se mostró más efectivo que el placebo en los desenlaces del cambio del PLMSI, calidad del sueño y en la calidad de vida. Los agonistas dopaminergicos, dentro de los cuales está incluido el pramipexol, son más efectivos que la levodopa para los desenlaces de escala de síntomas IRLS. Al comparar el pramipexol de forma indirecta con el ropirinole (agonista dopaminergico) no se observaron diferencias estadísticamente significativas. Seguridad: Los eventos adversos son más frecuentes en el de grupo tratamiento con agonistas dopaminergicos (dentro de los cuales se encuentra el pramipexol) comparado con placebo. No se encontraron diferencias en seguridad entre el pramipexol y el placebo.(AU)

Hiperprolactinemia en la población infantojuvenil: un tema vigente / Hyperprolactinaemia in child an adolescent population: a current issue

La hiperprolactinemia constituye la altelaración endocrina más común del eje hipotálamo-hipofisario, aunque su prevalencia en la población infantojuvenil no está aún claramente definida. Además de la Prolactina (PRL) nativa (23Kda), se han descripto numerosas variantes moleculares, algunas de ellas con menor o ausente actividad biológica. Todo proceso que interrumpa la secreción de dopamina, interfiera con su liberación hacia los vasos portales hipofisarios o bloquee los receptores dopaminérgicos de las células lactotróficas, puede causar hiperprolactinemia. Si bien la patología tumoral constituye el diagnóstico de mayor relevancia, los prolactinomas son poco frecuentes en nios y adolescentes, aunque tienen en general una particular presentación clínica: de acuerdo con nuestra experiencia, el retraso puberal puede observarse en aproximadamente el 50% de las pacientes de sexo femenino. En pacientes con hiperprolactinemia asintomática debe evaluarse la presencia de proporciones alteradas de isoformas de PRL. La cromatografía en columna con sephadex G100, la precipitación con suspención de proteína A o con PEG y la ultracentrifugación constituyen los métodos más frecuentemente empleados para la detección de las distintas isoformas de PRL. En nuestra experiencia la B PRL constituyó el 6,6 - 32,6% de la PRL total y la BB PRL contituyó el 40 y el 72% de çesta en este gruo de pacientes. En cuanto al tratamiento por su efectividad y tolerancia, los agonistas dopaminérgicos constituyen la terapia inicial de elección en pacientes en edad pediátrica. La bromocriptina y la cabergolina han sido empleadas y con resultados similares a los de los pacientes adultos.

Treatment of juvenile Parkinson disease and the recurrent emergence of pathologic gambling.

OBJECTIVE: To describe the recurrent emergence of pathologic gambling (PG) during the sequential treatment of a patient with Juvenile Parkinson disease (PD) with different dopamine agonists. METHOD: Single case report. RESULTS: A patient with Juvenile PD developed PG soon after beginning treatment with pergolide, a mixed D1/D2 dopamine agonist that is also supposed to exhibit D3 activity. This behavior remitted upon the discontinuation of the drug. A subsequent therapeutic trial with pramipexole, a dopamine agonist with preferential D3 dopamine receptor activity, resulted in the recurrence of PG. Remarkably, previous treatment with levodopa was not associated with this side effect. CONCLUSIONS: These findings seem to confirm previous suggestions that dopaminergic hyperactivity plays an important role in the pathogenesis of PG. They further indicate that patients with PD may develop PG as a side effect of more than one dopamine agonist. There is still no consensus regarding the best strategy to deal with this potentially disturbing phenomenon.

Use of dopamine agonist pergolide in outpatient treatment of cocaine dependence.

The dopamine agonist pergolide was evaluated in the treatment of 42 men who manifested cocaine dependence in a single-blind, 4-week-long placebo-controlled study, during 1998-1999 in São Paulo, Brazil. The patients were randomly assigned to two groups: the first group received pergolide (0.05-0.2 mg per day) and the second group received placebo (one to four tablets per day). Urine toxicology screens were obtained. The groups were compared in terms of depressive symptoms, "craving," use of cocaine, side effects of medications, results of urine tests, and retention in treatment. At 3 months' follow-up, the participants were reassessed. No differences were found between the two groups.

Fármacos antiparkinsonianos / Anti-Parkinson drugs

La enfermedad de Parkinson requiere la administración de diversos fármacos. En el siguiente artículo se describen las diferentes drogas utilizadas, -agentes dopaminérgicos, anticolinérgicos y neuroprotectores- sus modos de acción, efectos adversos y precauciones y advertencias (AU)

Fármacos antiparkinsonianos / Anti-Parkinson drugs

La enfermedad de Parkinson requiere la administración de diversos fármacos. En el siguiente artículo se describen las diferentes drogas utilizadas, -agentes dopaminérgicos, anticolinérgicos y neuroprotectores- sus modos de acción, efectos adversos y precauciones y advertencias

Tratamento farmacológico da doença de Parkinson: agonistas dopaminérgicos diretos / Pharmacological treatment of Parkinson's disease: direct dopaminergic agonists

A doença de Parkinson idiopática (DP) é um dos problemas neurológicos mais frequentes. Apesar de ainda não ter cura, existem numerosos recursos para obter melhora sintomática prolongada. Entre as drogas existentes, os agonistas dopaminérgicos diretos vêm ocupando lugar de destaque no tratamento dessa doença, em suas diversas fases evolutivas. A presente revisão tem por objetivo apresentar os fundamentos neurobiológicos (sistema dopaminérgico, gânglios da base e seus circuitos) em condições normais e patológicas, assim como as características dos diversos agonistas diretos, ergolínicos e nãoðergolínicos. Esperaðse assim um melhor compreensão da ação desse grupo de drogas nas diversas etapas evolutivas da DP, para utilização em monoterapia ou de modo adjuntivo, visando o melhor controle das manifestações típicas da doença, assim como prevenir ou atenuar as freqüentemente incapacitantes complicações motoras (flutuações, discinesias)

Utilizaçäo do agonista dopaminérgico pergolida no tratamento da "fissura" por cocaína / Use of the dopaminergic agonist pergolide in the treatment of cocaine craving

O estudo avaliou a eficácia e a segurança terapêutica do agonista dopaminérgico pergolida no tratamento ambulatorial da "fissura" por cocaína. Métodos: Participaram de estudo controlado simples-cego, com duraçäo de quatro semanas, em tratamento ambulatorial, 42 pacientes do sexo masculino com idade entre 18 e 50 anos, com diagnóstico de dependência de cocoaína pelo DSM-IV e primeiro grau completo. Transtornos clínicos e/ou psiquiátricos que necessitassem de internaçäo, uso de medicaçäo psiquiátrica, quadros psicóticos prévios independentes do consumo de cocaína e hipersensibilidade à pergolida foram critérios de exclusäo. Os pacientes foram divididos aleatoriamente em dois grupos: o primeiro recebeu pergolida (0,05-0,2 mg ao dia), e o segundo, placebo (1 a 4 comprimidos ao dia). Os grupos foram comparados quanto à "fissura" por cocaína. Conclusäo: A amostra pequena e o uso de medicaçäo por tempo curto podem ter influído nos resultados. A pergolida se mostrou segura, com poucos efeitos colaterais. A pergolida näo se mostrou superior ao placebo no tratamento da "fissura" por cocaína

Cocaína: bases biológicas da administraçäo, abstinência e tratamento / Cocaine: biological basis of administration, withdrawal and treatment

O aumento do consumo de cocaína nas últimas duas décadas foi acompanhado por uma melhora do conhecimento dos mecanismos biológicos relacionados ao uso, abuso e dependência desta droga. Entender esses mecanismos ajudará o clínico a compreender os comportamentos e sintomas dos usuários, bem como as possibilidades de tratamentos biológicos existentes. Os objetivos desta revisäo säo:1. Avaliar a neurobiologia da cocaína, as alteraçöes que provoca nos usos agudo e crônico, os possíveis mecanismos de dependência e da síndrome de abstinência, além das repercussöes neuroendócrinas do uso crônico. 2. Relacionar a farmacoterapia disponível, avaliando sua eficácia a partir de estudos já realizados e apontar novos estudos em andamento

Tratamiento médico de los tumores hipofisiarios productores de prolactina y hormona de crecimiento / Medical treatment of prolactin and growth hormone secreting pituitary tumors

Advances in medical treatment of prolactinomas and acromegaly in the last 20 years are analyzed. Dopaminergic drugs as bromocriptine, lisuride, pergolide and terguride successfully control hyperprolactinemia, reduce tumor size and cause clinical improvement. New long lasting medications with less adverse effects such as cabergoline, with oral weekly administration, and the repeatable monthy injectable form of bromocriptine (Parlodel LAR, Sandoz) may be the treatment of choice for prolactinomas. Dopaminergic medications are less effective in acromegaly. The higher doses required induce more collateral effects. An important step has been the incorporation of long lasting somatostatin analogues such as octreotide (for sbc use tid) intramuscular every 28 days injectable Sandostatin LAR and lanreotide SR (Somatuline, Ipsen Biotech), injectable every 10 to 14 days. Medical treatment of acromegaly is not, at the present, an alternative to surgery. However, the development of long lasting specific drugs may become, in the future, the choice or an alternative in the treatment of acromegaly

Utilidad del mesilato de pergolide en la enfermedad de Parkinson / Ytility of pergolide mesylate in Parkinsonïs disease

Estudiamos a quince pacientes con enfermedad de parkinson de más de 5 años de evolución, en un estudio clínico abierto. Todos ellos presentaban efectos indeseables secundarios al uso de levodopa, así como fenómeno de Fin de dosis. Todos tomaban levadopa y se les agregó mesilato de pergolide en una dosis promedio de 3 mg, en 24 horas. El estudio duró 12 semanas y las evaluaciones se realizaron cada dos semanas. Cinco pacientes abandonaron el tratamiento por presentar efectos colaterales, el resto mejoraron en cuando a la clasificación de Hoen y Yarth, la escala breve de la enfermedad de Parkinson y la velocidad de empuñamiento en ambas manos con P-0.005.

Chronic activation of dopamine receptors in the female infantile rat: effect on hypophyseal hormones and on the onset of puberty.

In the female rat the period from days 7-20 of age is special with regard to regulation of hypophyseal hormone secretion. This period is characterized by high FSH levels and the occurrence of sporadic LH peaks. As it has been reported that haloperidol could enhance both gonadotropins at 12 days of age and not at later ages, it was of interest to treat rats during the infantile period with pergolide, a dopaminergic agent of long action, and evaluate its effect on hormone levels and puberty onset. Three different schedules of drug injections were applied: 1) daily injections (0.05 mg/kg.day) on days 1-10, 2) daily injections on days 5-14, and 3) daily injections on days 11-20. It was found that only animals treated with daily injections of pergolide on days 11-20 showed an advance in the age of vaginal opening and first estrus compared to distilled water-injected controls. Thus, the rest of the experiments were performed using injection schedule 3. In this group of animals serum LH and FSH levels were decreased 3 and 6 days after the beginning of pergolide treatment (13 and 16 days of age); at 19 days of age pergolide did not modify gonadotropin levels. One day after the end of pergolide treatment (day 21 of age), there was a rebound in LH levels in drug-injected rats, and a nonsignificant increment in FSH levels was observed. There were no differences in serum gonadotropin levels on days 22, 23, and 25 or peripubertally (29, 33, or 36 days of age). On the other hand, pergolide did not significantly modify PRL levels during the treatment, probably due to the already low values of PRL at these ages. Furthermore, PRL levels were not different between control and pergolide-injected rats at all other ages studied. After puberty onset, animals were observed for eight consecutive cycles, and both groups cycled regularly. Furthermore, PRL and gonadotropins levels were similar at diestrus and proestrus. To evaluate if pergolide treatment during the infantile period had caused permanent alteration in dopamine receptor sensitivity, animals were injected with haloperidol (0.1 or 0.25 mg/kg), and PRL release was evaluated. There were no differences in the hyperprolactinemic effect of the drug between groups. Finally, gonadotropin sensitivity to LHRH was similar in adult female rats in proestrus of both groups. The present results suggest that chronic activation of dopamine receptors during the infantile period evokes specific responses on gonadotropin secretion and advances the age of puberty onset.(ABSTRACT TRUNCATED AT 400 WORDS)

Positive interaction between alpha-1 adrenergic and dopamine-2 receptors in locomotor activity of normo and supersensitive mice.

In normosensitive mice either the D1 antagonist SCH 23390 or the D2 antagonist sulpiride inhibited the reversion of reserpine-induced akinesia elicited by the mixed D1/D2 agonist pergolide. In mice rendered supersensitive by a five days' reserpine treatment, sulpiride did not prevent the pergolide-induced reversal of akinesia while SCH 23390 disclosed two subpopulations of mice. One population responded to pergolide with marked locomotor activity whereas in the other subpopulation this response was absent. However, all mice challenged with pergolide failed to reverse reserpine-akinesia after alpha-methyl-p-tyrosine (AMPT) pretreatment. The alpha 1/alpha 2 agonist clonidine restored the ability of pergolide to overcome reserpine akinesia in supersensitive mice pretreated with SCH 23390. Clonidine reversed the akinesia in supersensitive mice but in normal animals it did not. However, in these last conditions, the combined use of clonidine plus the D2 agonist LY 171555 was effective to induce locomotion. Neither AMPT nor SCH 23390 inhibited this response whereas the alpha-adrenergic antagonists prazosin and yohimbine did prevent it. The alpha 2 agonist B-HT 920 failed to induce locomotor responses when given together with LY 171555. The same occurred with the D1 agonist SKF 38393 when given together with clonidine. The combined use of SCH 23390 plus prazosin in chronic reserpinized mice prevented pergolide-induced locomotion. Adrenergic stimulation, acting on alpha 1 receptors, could be an alternative to D1 stimulation as a necessary factor to obtain D2-induced motor responses under normo and supersensitive conditions.

Natural and artificially induced ovulatory models related to lactation in the rat: role of prolactin.

The presence and the importance of a preovulatory prolactin (PRL) peak was determined in four, natural or artificially induced, ovulatory models related to lactation in the rat. Gonadotrophin peaks were determined in the afternoon preceding ovulation in four models: postpartum ovulation (PPO), ovulation after the lactational period (AL) (natural models), ovulation after litter removal at midlactation (ML), and ovulation in lactating rats (LR) (artificially induced models). In PPO, AL, and ML rats a preovulatory PRL surge was detected, showing that its presence is a common characteristic of ovulation in the rat. Bromocriptine inhibition of PRL levels in PPO and AL rats did not modify the percentage of rats which ovulated. In contrast, this treatment was able to significantly increase ovulation percentage in ML rats. Moreover, in LR rats strong dopaminergic inhibition of PRL levels, induced by pergolide, was necessary for ovulation to take place, but if pergolide-treated rats were injected with ovine PRL ovulation was completely inhibited. These data suggest that while a PRL surge seems to be always present in natural ovulatory models, it is not essential for ovulation to take place. On the other hand, in artificially induced ovulatory models, suppression of prolactinemia is able to induce ovulation or to increase the percentage of rats which ovulated. This effect of PRL on ovulation may be direct or indirect.

Postsynaptic bimodal effect of sulpiride on locomotor activity induced by pergolide in catecholamine-depleted mice.

In reserpinized (5 mg/kg, s.c.) mice treated with alpha-methyl-p-tyrosine (200 + 100 mg/kg, i.p.), increasing doses of the D-2 antagonist sulpiride had varying effects on locomotor activity induced by the mixed D-1/D-2 agonist pergolide (2 mg/kg, s.c.). Low doses of sulpiride (1 mg/kg, i.p.) significantly enhanced this activity whereas at higher doses (50 mg/kg) an inhibitory effect was observed. Amphetamine (3 mg/kg, i.p.) failed to reverse akinesia in this animal model, precluding the possibility of a presynaptically mediated phenomenon; in contrast, mice receiving reserpine alone showed a high degree of locomotor activity when challenged with amphetamine. The bimodal effect of sulpiride is thought to be mediated either by two different D-2 receptors located on the same cell or by the same receptor with different topographical localization on postsynaptic neurons mediating opposite functions.

Biphasic effects of dopamine D-2 receptor agonists on sleep and wakefulness in the rat.

The effects of the dopamine (DA) receptor agonists apomorphine, bromocriptine and pergolide were compared with those produced by a DA receptor antagonist, haloperidol, in rats implanted with electrodes for chronic sleep recordings. Apomorphine (0.025-2.0 mg/kg) and bromocriptine (0.25-6.0 mg/kg) induced biphasic effects such that low doses decreased wakefulness (W) and increased slow wave sleep (SWS) and REM sleep (REMS), while large doses induced opposite effects. The effects of pergolide (0.05-0.5 mg/kg) on W and SWS were also biphasic, while REMS was suppressed over the range of dosages given. At 0.040 mg/kg, haloperidol increased W, while at 0.160 mg/kg it produced the opposite effect. Pretreatment with haloperidol (0.020 mg/kg) in a dose which preferentially acts at presynaptic sites reversed the effects of low doses of apomorphine, bromocriptine or pergolide on sleep and W. However, the compound differed substantially in its ability to block agonist effects. The increase in sleep after low doses of apomorphine, bromocriptine or pergolide could be related to activation of presynaptic D-2 receptors located on DA axons of mesolimbic and mesocortical systems. In addition, inhibition of norepinephrine and acetylcholine neurons having inhibitory D-2 receptors could contribute to the increase of sleep after small doses of the DA agonists.

Alpha-2-adrenoceptor-mediated effects of pergolide.

The alpha-adrenoceptor-mediated effects of pergolide were investigated in a number of biochemical and pharmacological test systems. In radioligand binding studies, pergolide more effectively competed for alpha 2-adrenoceptors than for alpha 1-adrenoceptors in membranes prepared from rat cerebral cortex. Consistent with this finding was the observation that pergolide was several orders of magnitude more effective in activating presynaptic alpha 2-adrenoceptors in rat vas deferens to inhibit stimulation-evoked [3H]-norepinephrine release than in activating postsynaptic alpha 1-adrenoceptors in the same tissue to produce a contractile response. Pergolide elicited a potent vasopressor response in pithed rats that was highly sensitive to antagonism by the selective alpha 2-adrenoceptor antagonist, yohimbine, and resistant to blockade by the selective alpha 1-adrenoceptor antagonist, prazosin, suggesting that pergolide selectively activates postsynaptic vascular alpha 2-adrenoceptors. The results of the present study indicate that the alpha-adrenoceptor-mediated effects commonly associated with pergolide result from selective stimulation of alpha 2-adrenoceptors.