Dopamine receptor agonists
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No response: case report A 55-year-old man exhibited no response to dopaminergic treatment with rotigotine, pramipexole and levodopa/carbidopa/ entacapone for Parkinson variant multiple system atrophy (MSA-P). The man had incomplete bladder emptying at the age of 53 years, which was initially suspected to be due to prostate hyperplasia. He had undergone a partial transurethral prostate resection, which did not improve the urinary symptoms. He further developed motor signs including rigidity, gait disturbances and bradykinesia. A DaT scan revealed bilateral nigrostriatal dopaminergic denervation. He started receiving dopaminergic treatment with transdermal rotigotine 8mg daily, but due to insufficient motor control, rasagiline [route and dosage not stated] and additional dopaminergic medications pramipexole and levodopa/carbidopa/ entacapone were added by the neurologist up to a levodopa equivalent daily dose (LEDD) of 1479mg. At the age of 55 years, he presented with worsening motor symptoms, which did not respond to the dopaminergic medications. He also exhibited slurred speech, erectile dysfunction, urge incontinence, and symptoms of orthostatic intolerance including blurred vision, weakness and recurrent syncope consistent with signs of MSA. A diagnosis of REM sleep behavior disorder was also confirmed by polysomnography, and trazodone was initiated. Cardiovascular autonomic function testing revealed severe neurogenic orthostatic hypotension, and the neurourological examination revealed bladder atonia. An acute levodopa challenge showed no motor improvement. The findings and criteria fulfilled the diagnosis of a probable Parkinson variant multiple system atrophy (MSA-P). The man started an intensive physiotherapy program. At follow-up after being treated with a LEDD of 1164 mg (at the age of 56 years), he exhibited overt autonomic failure and left-sided akinetic-rigid parkinsonian syndrome (Hoehn and Yahr stage 2). He started self-treatment with an OTC food supplement containing cannabidiol and experienced improvement in symptoms of leg discomfort, agitation cramps, general well-being and quality of sleep. Trazodone was discontinued. No change in his other medications or LEDD was made. No syncope occurred following the initiation of the cannabidiol food supplement. Leys F, et al. Effects of self-administered cannabidiol in a patient with multiple system atrophy. Clinical Autonomic Research 30: 355-356, No. 4, 19 Jun 2020. Available 803503677 from: URL: http://doi.org/10.1007/s10286-020-00704-2
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Reactions 26 Sep 2020 No. 1823
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