RESUMO
Movement disorders (MD) encompass acute and chronic diseases characterized by involuntary movements and/or loss of control or efficiency in voluntary movements. In this review, we covered situations in which the main manifestations are MDs that pose significant risks for acute morbidity and mortality. The authors examine literature data on the most relevant MD emergencies, including those related to Parkinson's disease, acute drug reactions (acute dystonia, neuroleptic malignant syndrome, serotonergic syndrome and malignant hyperthermia), acute exacerbation of chronic MD (status dystonicus), hemiballism and stiff-person syndrome, highlighting clinical presentation, demographics, diagnosis and management.
Os distúrbios do movimento (DM) englobam doenças agudas e crônicas caracterizadas por movimentos involuntários e/ou perda do controle ou eficiência em movimentos voluntários. Nesta revisão, incluímos situações nas quais as principais manifestações são DM que representam risco devido à alta morbidade e mortalidade. Os autores revisaram aspectos relacionados às principais emergências em DM, incluindo aquelas relacionadas a doença de Parkinson; reações causadas por drogas (distonia aguda, síndrome neuroléptica maligna, síndrome serotoninérgica, hipertermia maligna); exacerbação aguda de DM crônicos (status distonicus); hemibalismo e síndrome da pessoa rígida. São destacados a apresentação clínica, os dados demográficos, o diagnóstico e o tratamento.
Assuntos
Humanos , Tratamento de Emergência , Transtornos dos Movimentos/diagnóstico , Transtornos dos Movimentos/terapia , Doença AgudaRESUMO
Depression is a frequent mental disorder in the general population. Approximately 3.7% of the population will suffer a major depressive episode throughout life. Pharmacological treatment with selective serotonin receptor inhibitors (SSRIs) is useful to treat this condition and other mental disorders. Citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine and sertraline, which constitute this group, are characterized by having an easy way of administration and a very extensive security profile. Objectives The objectives in this revision were: 1. To establish current indications of selective serotonin receptor inhibitors, using as basis those authorized by the Food and Drug Administration (FDA) of the United States of America. 2. To describe the mechanisms that explain antidepressant action. Initially, the SSRIs inhibit the reuptake of serotonin at the synaptic cleft; later there is a downregulation of the 5HT1A receptors; and finally antidepressants raise the levels of brain derived neurotrophic factor (BDNF). 3. To present its way of administration and dosage. 4. To describe frequent collateral effects and those specifically associated to this group of antidepressants and the recommended treatment. Results SSRIs antidepressants are the first choice treatment in depression, in the anxiety disorder, the obsessive-compulsive disorder, the post-traumatic stress disorder, bulimia nervosa and the premenstrual dysphoric disorder. At present, SSRIs displace benzodiacepines in the treatment of generalized anxiety disorder, just as they displaced tricyclic antidepressants in the past. Depressed patients show less activity than normal of the serotonin neurotransmitter (serotonergic hypothesis of depression) and the reuptake blockade at the site of the serotonergic presinaptic receptors 5HT1A, 5HT2C and 5HT3C increases neurotransmission in this system. Desensitization of autoreceptors 5HT1A and the downregulation of the 5HT2 receptors coupled to the G protein, a late effect of the SSRIs, result in the improvement of the depressive symptoms. The mechanism that explains the relatively late antidepressant effect seems to be different to the acute and fast serotonergic effect responsible of improvement in the premenstrual dysphoric disorder. Moreover, these antidepressants, in the same way than mood stabilizers and electroconvulsive therapy, increase serum levels of the brain-derived neuronal growth factor, as well as other neurotrophic factors. Although the SSRIs dosages are variable, it is possible to start antidepressant treatment with therapeutic doses in the majority of cases; at the same time, if necessary, it is possible to augment them gradually up to the largest dose, with a wide security margin. Their most frequent collateral effects occur in the gastrointestinal system, in the sexual response and on bone density. Nevertheless, there are collateral effects specifically related to the use of these antidepressant medications: 1. The serotonergic syndrome, characterized by changes in the mental status, autonomic hyperactivity and neuromuscular anomalies. 2. The syndrome of inappropriate secretion of antidiuretic hormone, which occurs in 25% of the elder depressed patients treated, and which is characterized by a high serum osmolarity, low urinary osmolarity and hyponatremia. Its manifestations are malaise, myalgias, drowsiness and headache, but it may produce also confusion, convulsions and coma. 3. Gastrointestinal bleeding mainly and cutaneous bleeding: Use of SSRIs raises 2 to 4 times the risk of bleeding. When the patient takes aspirin it is raised up to 7 times, and with the concomitant use of anti-inflammatory drugs, by nearly 16 times. Other risk factors are age, the antecedent of bleeding and the potency of SSRIs to inhibit the serotonin reuptake. 4. The discontinuation syndrome, lesser with fluoxetine, and greater with paroxetine and sertraline. It appears by the second day and it lasts two weeks. Its manifestations are nausea, headache, paresthesias, nasal congestion and general malaise. They are due to the decrease in serotonin levels at the synaptic cleft. 6. Effects on the newborn when the SSRIs are used during pregnancy consist in specific congenital malformations. Sertraline has been associated to omphalocele, ventricular septum heart defects and anencephaly. Fluoxetine is associated to craniosynostosis and paroxetine to heart defects, gastroschisis, neural tube defects, omphalocele and anencephaly also. Its use also increases the range of spontaneous abortions up to 1.45 times, premature delivery and low birth weight, problems in the early newborn period (respiratory problems and hypotony), hypoglycemia, cyanosis, restlessness, convulsions and low Apgar. Its use during the third trimester can cause persistent lung hypertension. Although it is a rare condition, it is associated to a mortality range of 10% to 20%. 8) Little is known about the effects caused by the use of SSRIs during breastfeeding. In the case of sertraline and paroxetine, these antidepressant drugs are not detected in the child's serum; on the other hand, serum levels of citalopram were 1.9 nmol/L, fluoxetine 47 nmol/L, and venlafaxine 91 nmol/L. In the available studies, neither behavioral effects nor effects in the development of the newborn were observed. 9) Suicide risk or suicidality. Although the antidepressant treatment lowers both, ideation and the frequency of suicides in the patients treated, the FDA has established a series of general recommendations for the management of patients who start the treatment with antidepressants. To start with the lowest dose, to make an appointment weekly during six consecutive weeks, to recommend and facilitate contact via telephone, to prohibit the use of alcohol and drugs, to ask on each date about suicidal thoughts or behaviors or about self-mutilation, to document the information in the file and to use supportive psychotherapy or cognitive, behavioral or interpersonal therapies.
La depresión es un trastorno mental que afecta a 3.7 % de la población. Los antidepresivos inhibidores selectivos de la recaptura de serotonina (ISRS) resultan útiles en el tratamiento de éste y otros trastornos mentales. El citalopram, escitalopram, fluoxetina, fluvoxamina, paroxetina y sertralina constituyen este grupo de fácil administración y con un amplio perfil de seguridad. Objetivos 1) Establecer las indicaciones actuales de los antidepresivos ISRS. 2) Describir los mecanismos que explican su acción antidepresiva. 3) Describir los efectos secundarios frecuentes y aquéllos específicamente relacionados con este grupo antidepresivo. Resultados Los antidepresivos ISRS son el tratamiento de elección para la depresión, los trastornos de angustia, de ansiedad generalizada, obsesivo-compulsivo, de estrés postraumático, disfórico premenstrual y la bulimia nervosa. Los pacientes deprimidos muestran una actividad menor a la normal del neurotransmisor serotonina. La inhibición de la recaptura de la serotonina sobre los receptores serotoninérgicos presinápticos 5HT1A, 5HT2C y 5HT3C aumenta la neurotransmisión en este sistema. La desensibilización de los autorreceptores 5HT1A y la regulación hacia abajo (downregulation) de los receptores 5HT2 acoplados a la proteína G, efecto tardío de los ISRS, dan por resultado la mejoría de los síntomas depresivos. El mecanismo que explica el efecto antidepresivo relativamente tardío parece ser distinto al efecto serotoninérgico agudo y rápido responsable de la mejoría en el caso del trastorno disfórico premenstrual. Estos antidepresivos, como los estabilizadores del ánimo y la terapia electroconvulsiva, incrementan los niveles séricos del factor de crecimiento neuronal cerebral, así como de otros factores neurotróficos. Aunque las dosis de los ISRS son variables, en la mayoría de los casos es posible iniciar el tratamiento antidepresivo con dosis terapéuticas e incrementarlas paulatinamente hasta las dosis máximas con seguridad. Sus efectos secundarios más frecuentes son gastrointestinales, en la respuesta sexual y sobre la densidad ósea. Los efectos secundarios específicamente relacionados con el uso de estos antidepresivos son: 1. El síndrome serotoninérgico, caracterizado por cambios en el estado mental, hiperactividad autonómica y anomalías neuromusculares. 2. El síndrome de secreción inapropiada de hormona antidiurética, que se caracteriza por osmolaridad sérica alta, urinaria baja e hiponatremia, así como por mialgias, letargo, cefalea e incluso confusión, convulsiones y coma. 3. El sangrado, principalmente de tubo digestivo y cutáneo. El uso de los ISRS aumenta el riesgo de sangrar entre dos y cuatro veces. Cuando el paciente usa aspirina, el riesgo aumenta hasta siete veces y con el uso concomitante de antiinflamatorios, cerca de 16 veces. La edad, el antecedente de sangrado y la capacidad de inhibir la recaptura constituyen también factores de riesgo. 4. El síndrome de descontinuación, menor con la fluoxetina, mayor con la paroxetina y sertralina, aparece a partir del segundo día y su duración es de dos semanas. Manifestaciones como náusea, cefalea, parestesias, congestión nasal y malestar general se deben a la disminución de los niveles de serotonina en la sinapsis. 5. Los efectos sobre el producto cuando los ISRS se utilizan durante la gestación consisten en malformaciones congénitas específicas. La sertralina se ha asociado a onfalocele, defectos del septum cardíaco y anencefalia. A su vez, la fluoxetina se ha asociado a craneosinostosis y defectos cardíacos. Y la paroxetina a defectos cardíacos, gastrosquisis, defectos del tubo neural y también a onfalocele y anencefalia. Su uso también aumenta la tasa de abortos espontáneos hasta 1.45 veces, parto prematuro y bajo peso al nacer, problemas en el neonato inmediato (problemas respiratorios e hipotonía), hipoglucemia, cianosis, inquietud, convulsiones y Apgar bajo. Su uso durante el tercer trimestre puede ocasionar hipertensión pulmonar persistente que, aunque es rara, se asocia a una mortalidad de 10- 20 %. 6) De los efectos por el uso de ISRS durante la lactancia se conoce poco. En el caso de la sertralina y la paroxetina no se detectan estos antidepresivos en el suero del niño; en cambio, los niveles séricos de citalopram fueron de 1.9 nmol/L, de fluoxetina 47 nmol/L y de venlafaxina de 91 nmol/ L. En los estudios disponibles no se observaron efectos conductuales o en el desarrollo del recién nacido. 7) Suicidalidad o riego suicida. Aunque el tratamiento antidepresivo disminuye tanto la ideación y la frecuencia de suicidios en los pacientes tratados, la FDA ha establecido una serie de recomendaciones para el manejo de pacientes que inician el tratamiento con antidepresivos ISRS: Iniciar con la dosis más baja, citar semanalmente a los pacientes durante 6 semanas consecutivas, recomendar y facilitar el contacto telefónico, prohibir el uso de alcohol y drogas, interrogar en cada ocasión sobre pensamientos y comportamientos suicidas o autolesivos, documentar en el expediente la información y usar psicoterapia de apoyo, cognitivo-conductual o interpersonal en el tratamiento.