在斋戒月期间管控巴金森氏症


  【24drs.com】本回顾报告之目的是,患有巴金森氏症(PD)的穆斯林患者在斋戒月期间,须于黎明和黄昏之间禁食─包括禁止服用药物时,应如何控制病况。
  
  这篇在线发表于12月27日JAMA神经学期刊的报告中,法国Nantes大学附属医院Philippe Damier医师以及Al-Khaldiya科威特大学Jasem Al-Hashel医师解释,根据进行斋戒月的季节,禁食时间为每天11至18小时不等,这会导致PD患者的一些问题,这些患者大多有使用levodopa这种半衰期相当短的药物作为他们的主要疗法。
  
  他们指出,levodopa的给药剂量至少是每天3次,在运动波动阶段,每天服用levodopa的次数在某些患者可以增加到超过10次。延迟给药常常会导致运动症状以及非运动症状再度出现,例如:疼痛、焦虑、忧郁情绪、盗汗或呼吸困难。
  
  在最严重的情况下,患者可能僵硬无法移动、肌肉僵硬到几乎不能一般地移动,这可能会导致脱水、发烧和横纹肌溶解。最后,任何突然地停用多巴胺替代药物的情况会与危及生命的恶性高热症候群有关。
  
  作者们表示,每天服用1次抗巴金森药物的初期阶段患者,应该能够遵循禁食,不会有重大的困难和风险。
  
  他们认为,至于轻度到中度波动的患者,如果他们的每日levodopa治疗剂量相当于小于300 mg且可以耐受效果持续时间较长的多巴胺致效剂,也可以获得控制。
  
  他们建议,将这类患者转换为等效剂量、每天1次的缓释多巴胺致效剂,或使用经皮贴片。可以用控制释放型的levodopa制剂补充,在开始斋戒禁食的黎明之前服用,然后在黄昏停止进食之后服用。
  
  他们建议,在斋戒月前至少2周开始这些治疗变化,以便有调整空间。
  
  在更严重的情况下,他们认为,治疗是困难的,并且对患者的健康造成风险。应该提醒患者,宗教本文清楚地指出,慢性病患者不需要禁食。但是,如果患者仍然想要禁食,可以在较轻微的患者使用缓释型多巴胺致效剂与levodopa制剂的相同组合,不过,他们提醒,在斋戒月开始之前逐渐减少多巴胺置换药物的量是必要的,以防止恶性高热的风险。
  
  他们建议,在非空腹时间添加一个剂量的每天1次的单胺氧化酶B型抑制剂,可以帮助延长症状缓解,而且,在运动障碍的情况下,使用amantadine可能是有用的。
  
  作者们结论指出,斋戒月期间后,抗巴金森治疗应逐渐调整回来。
  
  他们指出,在缺乏此一主题之具体研究的情况下,斋戒月期间可采用的巴金森氏症最佳疗法、以及这段期间对于短期和长期之疾病控制的影响,仍有诸多问题存在。
  
  资料来源:http://www.24drs.com/
  
  Native link:Managing Parkinson's Disease During Ramadan

Managing Parkinson's Disease During Ramadan

By Sue Hughes
Medscape Medical News

How to manage Muslim patients with Parkinson's disease (PD) during the month of Ramadan, when fasting is advocated between dawn and dusk — including abstinence from medications — is the subject of a new review paper.

In the paper, published online in JAMA Neurology on December 27, Philippe Damier, MD, Centre Hospitalier Universitaire Nantes, France, and Jasem Al-Hashel, MD, University of Kuwait, Al-Khaldiya, explain that depending on the season in which Ramadan occurs, the fasting period varies from 11 to 18 hours a day. This causes problems for patients with PD, most of whom use levodopa, a drug with a very short half-life, as their mainstay therapy.

They note that levodopa is dosed at least three times a day, and at the stage of motor fluctuation, the daily number of levodopa intakes can increase to be more than 10 in some patients. A delay in drug administration often leads to the reappearance of motor symptoms as well as nonmotor symptoms, such as pain, anxiety, depressive mood, sweating, or dyspnea.

In the most severe cases, the patient might be frozen, hardly able to move with generalized muscle rigidity, which can lead to dehydration, fever, and rhabdomyolysis. Finally, any sudden withdrawal of dopamine replacement drugs is associated with the risk for a life-threatening malignant hyperthermia syndrome.

The authors say that a patient at the early stage of the disease with a once-daily administration of antiparkinsonian medication should be able to follow the fasting period without major difficulties and risks.

Patients with mild to moderate fluctuations can also be managed if they are treated with a daily levodopa equivalent dosage lower than 300 mg and are able to tolerate dopamine agonists, which have a longer-duration effect, they suggest.

They advise switching such patients to an equivalent dosage of an extended-release dopamine agonist administered once daily or by transdermal patch. This can be supplemented with a controlled-release levodopa formulation with one intake at dawn before the fasting starts and one intake at dusk when the fast is broken.

They recommend starting the changes to treatment at least 2 weeks before Ramadan to leave room for any adjustments.

In more severe cases, they say treatment is difficult and presents a risk to the health of the patient. The patient should be reminded that the religious texts clearly state that patients with a chronic disease do not need to fast, they write. But if the patient still wants to fast, the same combination of extended-release dopamine agonist and levodopa formulations can be used as in milder patients. However, it is essential to progressively reduce the amount of dopamine replacement drug before Ramadan starts to prevent the risk for malignant hyperthermia, they warn.

They suggest that adding a once-daily monoamine oxidase B inhibitor dose during the nonfasting time could help by extending the symptomatic relief, and the use of amantadine might be useful in the case of dyskinesia.

After the Ramadan period, the antiparkinsonian treatment needs to be adjusted back gradually, the authors conclude.

They add that in the absence of specific studies on this topic, many questions remain about the best way to adapt Parkinson's treatment during Ramadan fasting and the effect of that period on the short-term and long-term control of the disease.

Dr Damier reports he has received lecture fees from Medtronic, Teva Pharmaceuticals, and Novartis. The other authors have disclosed no relevant financial relationships.

JAMA Neurol. Published online December 27, 2016.

    
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