Transcript Balance Control Improves Following Replacement of Paroxetine

Balance Control Improves Following
Replacement of Paroxetine with
Venlafaxine and Levodopa in a Case of
Microvascular Dementia
The American Journal of Geriatric Pharmacotherapy 2011;9: 133-137
Jaime McDonald, Philippe Corbeil, Emmanuelle Porcher
Presented By:
Deepa Patel
Doctor of Pharmacy Candidate, 2012
Mercer University COPHS
July 8, 2011
Postural Instability
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Common complaint in geriatric patients
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Can be due to several disease states,
including Parkinson’s disease,
microvascular dementia, in addition to
numerous neurological disorders
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Falls may lead to decreased quality of life
and increased mortality
Study Design
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Case study of a single patient
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Funding by NSERC (Natural Sciences and
Engineering Research Council of Canada)
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Study authors were fully involved in every
aspect of the trial and publication and
received contracts from the drug
manufacturers
Patient Case
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86 y/o female with a 6 month
history of frequent falls
without injury and Parkinsonlike syndrome of the lower
limbs secondary to
microvascular dementia
Bilateral rigidity
Left-sided akinesia
Diminshed postural
adjustment reflexes
No signs of deconditinoing
Moderate ischemic leukopathy
of the paraventricular white
susbtance
Atropy of cerebral subcortical
and cerebellar regions
Current Medications
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Atorvastatin 40 mg daily
ASA 81 mg daily
Pantoprazole 40 mg daily
Paroxetine 20 mg daily
Vision, BP and HR normal
Ruled out: hypothyroidism,
peripheral neuropathy,
arterial insufficiecy
Microvascular Dementia
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Usually attributed to diseases that may
lead to ischemia such as diabetes mellitus
and dyslipidemia
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Neurotransmitters implicated in gait
disorders include
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Serotonin
Norepinephrine
Dopamine
Serotonin
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Involvement in balance control is
postulated as SSRI withdrawal has
detrimental effects on balance
Norepinephrine
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Involvement in balance control is
attributed to regulation of the mental
processes of attention and concentration
Dopamine
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Highly debated relationship with balance
control, but evidence of postural instability
in Parkinson’s disease strengthens the
hypothesis that dopamine contributes,
particulary when patients have eyes open
Intervention
Pt initially on Paroxetine 20 mg daily (tapered over 3 weeks)
Venlafaxine 37.5 mg twice daily
3 months: Venlafaxine 37.5 mg at bedtime
(reduced dose due to intolerability)
6 months: Venlafaxine 27.5 mg at bedtime +
Levodopa/carbidopa 100/25 mg, 1.5 tablets TID
Results
Primary outcome: Center of Pressure (CoP)
measured over 20 seconds, average of three
trials per treatment intervention performed
Conclusion
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Most improvement in balance control
when using combination therapy of
Venlafaxine (SNRI) and Levodopa
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Author suggests that for geriatric patients
on antidepressants, addition or switching
medications with differing mechanisms of
action may be an effective option for
helping alleviate balance control issues
Commentary
Strengths of Study
 Did not use
medications on the
Beer’s list
 Dosing was
appropriate for
disease state and
patient age
 Tapering of
medication was
appropriate
Weaknesses of Study
 Single patient study
 Most patients with
microvascular
dementia present with
numerous
concomitant disease
states including
diabetes mellitus and
hypertension, however
this patient did not
report such illnesses