Use of pramipexole in REM sleep behavior disorder: Results from a case series
ABSTRACT Rapid eye movement (REM) sleep behavior disorder (RBD) has a known association with other medical conditions, including narcolepsy and neurodegenerative diseases such as synuclienopathies. RBD is currently treated with clonazepam as a first-line therapy. Recent research suggests that the pathophysiology underlying RBD may involve a dopaminergic deficiency, given its association with Parkinson syndromes and restless legs syndrome (RLS). We report on the efficacy of pramipexole, a dopaminergic D2-3 receptor agonist, in the treatment of RBD.
The first 10 consecutive patients presenting with a history and polysomnographically confirmed RBD were given pramipexole as either a single dose before bedtime or as a divided dose regimen with the first dose given in the early evening and the second dose at bedtime. Medication was titrated to control RBD symptoms and the clinical response was monitored through interviews with the patient, spouse, and close family members during the course of the study at regularly scheduled follow-up visits.
The mean length of treatment was 13.1 months, and the average total evening dose of pramipexole at the end of the study was 0.89+/-0.31 mg. A divided dose regimen of pramipexole was used in 56% of patients remaining on pramipexole. We found that 89% of patients experienced either a moderate reduction or complete resolution in the frequency of RBD symptoms throughout the duration of the study. Moreover, 67% reported at least a moderate reduction in the severity of remaining symptoms.
Pramipexole markedly reduced the frequency and severity of RBD symptoms and appeared to maintain efficacy for up to 25 months as assessed at follow-up visits. Clonazepam may have numerous unwanted side effects in the elderly or narcoleptics with RBD, such as prominent sedation and the potential exacerbation of underlying obstructive breathing in sleep. The potential role of pramipexole in improving RBD and its associated dopamine deficient syndromes warrants further research in the use of dopaminergic agonists as a potential first-line alternative therapy for RBD.
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ABSTRACT: REM behavior disorder (RBD) is a parasomnia characterized by emergence of purposeful complex motor activity with an enactment of dream related activities. This condition is associated with vivid often violent dreams. In normal adults during REM, diffuse hypotonia of muscles occur and on polysomnography the limb and chin electromyographic (EMG) channels demonstrate a low voltage or even flat signal. In RBD, the EMG demonstrating intermittent loss of electromyographic atoniais one of the criteria for diagnosis. Diagnostic polysomnographyrequire capturing the complex dream behaviors on video and electroencephalography monitoring confirms that the behavior originated out of REM sleep. RBD can be either idiopathic or symptomatic of various underlying conditions and may in fact be a prodromal symptom of neurodegenerative disease. It can present acutely which is almost always induced by medications; or develop gradually over months to years. More than half of those with RBD will eventually exhibit signs and symptoms of a degenerative neurologic disorder. A Polysomnogram (PSG) is necessary to diagnose RBD, showing absence of REM sleep atonia and related abnormal behavior.
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ABSTRACT: Rapid eye movement (REM) sleep behavior disorder (RBD) is characterized by dream enactment behavior resulting from a loss of REM skeletal muscle atonia. The neurobiology of REM sleep and the characteristic features of REM atonia have an important basis for understanding the aggravating etiologies the proposed pharmacological interventions in its management. This review outlines the evidence for behavioral and therapeutic measures along with evidence-based guidelines for their implementation, impact on falls, and effect on polysomnography (PSG) while highlighting the non-motor, autonomic, and cognitive impact of this entity. PubMed databases were reviewed upto May 2013 in peer-reviewed scientific literature regarding the pathophysiology and management of RBD in adults. The literature was graded according to the Oxford centre of evidence-based Medicine Levels. An early intervention that helps prevent consequences such as falls and provides a base for intervention with neuroprotective mechanisms and allocates a unique platform that RBD portrays with its high risk of disease conversion with a sufficiently long latency. RBD provides a unique platform with its high risk of disease conversion with a sufficiently long latency, providing an opportunity for early intervention both to prevent consequences such as falls and provide a base for intervention with neuroprotective mechanisms.Annals of Indian Academy of Neurology 01/2015; 18(1):1-5. DOI:10.4103/0972-2327.150927 · 0.51 Impact Factor
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ABSTRACT: Sleep disorders are among the most common non-motor symptoms in Parkinson's Disease (PD). In some cases, symptoms can precede a diagnosis of PD by many years, but otherwise they are commonly encountered during the clinical care of patients. Unfortunately, sleep problems are under-recognized and subsequently inadequately addressed. In our experience, when properly addressed, physicians and patients are quickly aware of the often-debilitating nature of sleep dysfunction. This does not mean that solutions are easily attainable. Sleep in PD is held in a delicate balance, influenced by the disease process, medications, co-morbid symptoms, and a variety of other factors. For this reason, management of sleep in PD often requires an inter-disciplinary approach. Physicians should have an intimate knowledge of the many sleep problems apparent in PD, as well as appreciate the challenge presented by diverse therapeutic options that can both ameliorate and aggravate symptoms.Current Treatment Options in Neurology 08/2014; 16(8):304. DOI:10.1007/s11940-014-0304-7 · 2.18 Impact Factor