Neurology Update 2008

Karl E Misulis MD,PhD

January 2008

Key new developments

New protocols for treatment of dementia

We now use ChEIs for all stages of Alzheimer’s disease

Memantine is added to ChEIs for patients with moderate and severe dementia.

Rivastigmine patch has been a major advance – very effective and well tolerated.

Long acting version of donepezil and galantamine help with administration and compliance.

We believe with proper self-care and medical care, we can cut the incidence of dementia!

New treatments for Parkinsonism

Rasagiline is a MAOB-inhibitor which is used for initial therapy or with levodopa.

Rotigotine is a dopamine agonist in patch form, which is used for early-stage PD.

Selegiline is now available in oral-disintegrating form, reducing hepatic metabolism.

Levodopa is also available in oral-disintegrating form, helpful to induce a rapid start.

New-ish treatments for neuropathic pain

Pregabalin is effective for both large-fiber pain (e.g. PHN) and small-fiber pain (e.g. DPN). Also approved in the US for FMS.

Duloxetine is an SNRI effective for small-fiber pain (e.g. DPN). Especially helpful for patients with depression and pain.

New-ish ideas on treatment of migraine

Acute migraine treatment is usually triptans first line with analgesics as rescue. NSAIDs are sometimes used with the triptans. Ergots have been used must less due to recent concerns over vascular risk. Make sure to treat as early in the headache as possible.

Preventative therapy usually starts when migraines are about 4/month. The more established a headache pattern is, the harder it is to break. Most common reasons for failure of migraine preventatives are too low dose, and short treatment trial, and unrealistic expectations (no preventative stops all headaches).

Updated ideas on anti-thrombotic therapy for stroke and TIA

New data regarding use of antiplatelets in patients with stroke and TIA clarifies our protocols for primary and secondary stroke prevention. Recommendations are as follows:

·        Primary prevention = Aspirin

·        Secondary prevention of TIA or CVA with mainly cerebrovascular disease = Aspirin + Dipyridamole extended release.

·        Secondary prevention of TIA or CVA with prominent cardiovascular disease = Clopidogrel (without Aspirin)

·        Secondary prevention of TIA or CVA with high risk of cardiac emboli (atrial thrombus, low EF, septal defect) = warfarin.

·        High-risk of CVA due to Antiphospholipid antibody syndrome or other coagulopathy = warfarin usually.

·        Cerebral venous thrombosis = warfarin usually.

·        Cerebral artery dissection or severe intracranial stenosis = warfarin (often).

 

FAQ of neurology consultants

What are your favorite medicines for neuropathic pain?

Gabapentin, amitriptyline, pregabalin, and duloxetine. I may combine an antidepressant with an anticonvulsant, but I do not combine meds of the same class.

When do you have to treat a first seizure?

Seizure recurrence is greatest with any of the following: focal seizure, unprovoked seizure, abnormal exam, abnormal EEG, abnormal MRI, recurrent seizure. I usually recommend no med if all are not present but am more likely to offer if any high risk factors are present.

Which medicine do you start for Parkinsonism?

Young people usually start with a dopamine agonist, e.g. ropinerole, pramipexole. Older people start with levodopa/carbidopa at 25/100 tid, and advance.

What do you do for dyskinesias in patients with advanced parkinsonism?

Add amantadine. Can also reduce levodopa dose and substitute dopamine agonist. Changing to sustained-release or other long-acting formulation helps.

What do you do for motor fluctuations in patients with advanced parkinsonism?

Sustained-release levodopa preparations. COMT inhibitor. Sustained-release dopamine agonists. Multiple small doses of levodopa.

Which medicines are used for which seizures?

Absence epilepsy is often treated with ethosuximide, valproate, or lamotrigine.

Generalized tonic-clonic epilepsy is often treated with phenytoin or valproate.

Partial seizures are treated usually with carbamazepine, oxcarbazepine, or almost any one of the newer agents.

Myoclonic seizures are often treated with valproate or lamotrigine,.

Which meds do you use for migraine prevention?

Valproate is often used but should be avoided in women especially of child-bearing potential and in young patients, topiramate is preferred. TCAs are often very effective. Beta-blockers are still effective for many patients, especially children and young adults.

Which meds do you use for acute migraine treatment?

Triptans are first line for most patients. Most of us prescribe pure analgesics as rescue therapy. NSAIDs are sometimes combined with triptans for added benefit.

When does a patient need a statin?

We begin statins in most patients with stroke or TIA and often start them in the emergency room. All patients with stroke or TIA should be considered for statin regardless of lipid profile.

When does a patient with memory loss need a memory agent?

Presently, we are not sure that there is a protective effect of the memory meds, so we begin them when memory is a bother to the patient or family or when there has been a functional decline. There is only incomplete evidence that the course of the disease is altered.

What about treatment of non-Alzheimer’s dementias?

There is at least some evidence of efficacy of the meds for other dementias including Parkinson’s disease with dementia, vascular dementia, and fronto-temporal dementias. Therefore memory meds can be tried in these patients. Patients with vascular dementia must also have their vascular risk factors addressed.

When do you discontinue a memory drug?

When a patient has not responded to an agent in 2-3 months it should be discontinued and another tried. If a patient initially responded then progresses, this can be expected, but if it is thought that the drug has outlived its usefulness then discontinuation is tried. If the patient is worse 2 weeks after discontinuation then restart. If they are no worse, then consider another agent. When patients become total care the benefit of these meds is controversial.

Where can I find the ultimate answer to (almost) all neurologic questions?

Shared Care in Neurology, Shevlin, Misulis, Samuels.

Netter’s Concise Neurology, Misulis & Head

What are your biggest frustrations in American medicine?

Fibromyalgia/chronic fatigue, chronic pain with affective disturbance, pseudoseizures, parents, lawyers, and noncompliance.