A*******s
发帖数: 9638 | 1 池大你给发啊， lol
A 50 yrs old WF with a history of GERD and intractable nausea developed
ataxia for the past 1 month. She has been been on Reglan 10 mg po qid for
the past 6 months. This morning, she was seen by her PCP who immediately
realized it is reglan side effect. So the PCP discontinued the reglan.
You happened to be her doctor for other reasons and saw her on same day.
What do you do differently? |
C*****D
发帖数: 1299 | 2 你的周末也太早了吧？
【在 A*******s 的大作中提到】
: 池大你给发啊， lol
: A 50 yrs old WF with a history of GERD and intractable nausea developed
: ataxia for the past 1 month. She has been been on Reglan 10 mg po qid for
: the past 6 months. This morning, she was seen by her PCP who immediately
: realized it is reglan side effect. So the PCP discontinued the reglan.
: You happened to be her doctor for other reasons and saw her on same day.
: What do you do differently?
|
A*******s
发帖数: 9638 | 3 这个题有点难，所以我先搁这里，估计周末也不见得有正确答案。 ：）
【在 C*****D 的大作中提到】
: 你的周末也太早了吧？
|
h*******r
发帖数: 182 | 4 Intractable nausea, ataxia... Could she have paraneoplastic syndrome
affecting cerebellum? I would like to check tumor markers and PET/CT for
occult malignancy.
【在 A*******s 的大作中提到】
: 池大你给发啊， lol
: A 50 yrs old WF with a history of GERD and intractable nausea developed
: ataxia for the past 1 month. She has been been on Reglan 10 mg po qid for
: the past 6 months. This morning, she was seen by her PCP who immediately
: realized it is reglan side effect. So the PCP discontinued the reglan.
: You happened to be her doctor for other reasons and saw her on same day.
: What do you do differently?
|
A*******s
发帖数: 9638 | 5 A good try. She had a comprehensive workup for nausea. So far all negative.
Not weekend yet so take your time and keep trying. :)
【在 h*******r 的大作中提到】
: Intractable nausea, ataxia... Could she have paraneoplastic syndrome
: affecting cerebellum? I would like to check tumor markers and PET/CT for
: occult malignancy.
|
d**o
发帖数: 618 | 6 r/o NPH? MRI, or assess urinary incontinence and dementia |
M****a
发帖数: 577 | 7 对于nausea，很多医生都会先开zofran，不管用才开reglan，除非觉得病人的GI
motility有问题。这个病人吃了半年的reglan，GI motility的问题应该首先排除。做
过的workup里面有没有upper GI studies还有gastric emptying study？病人有没有糖
尿病？GERD做过手术没有？手术后有没有并发症？做过其他GI手术没有？
【在 A*******s 的大作中提到】
: 池大你给发啊， lol
: A 50 yrs old WF with a history of GERD and intractable nausea developed
: ataxia for the past 1 month. She has been been on Reglan 10 mg po qid for
: the past 6 months. This morning, she was seen by her PCP who immediately
: realized it is reglan side effect. So the PCP discontinued the reglan.
: You happened to be her doctor for other reasons and saw her on same day.
: What do you do differently?
|
y**j
发帖数: 10 | 8 Any elytes abnormality? Hyponatremia?
【在 A*******s 的大作中提到】
: 池大你给发啊， lol
: A 50 yrs old WF with a history of GERD and intractable nausea developed
: ataxia for the past 1 month. She has been been on Reglan 10 mg po qid for
: the past 6 months. This morning, she was seen by her PCP who immediately
: realized it is reglan side effect. So the PCP discontinued the reglan.
: You happened to be her doctor for other reasons and saw her on same day.
: What do you do differently?
|
|
c****l
发帖数: 1086 | 9 I like to check if there is any vitamin defeciency such as B12. |
A*******s
发帖数: 9638 | 10 NPH does have symptoms of ataxia but she has no dementia nor incontinence.
And it has nothing to do with Reglan.
【在 d**o 的大作中提到】
: r/o NPH? MRI, or assess urinary incontinence and dementia
|
|
|
A*******s
发帖数: 9638 | 11 She was seen by GI and I believe she was put on Reglan by a surgeon after
the workup. The detail is not very clear to me but there is no operation
needed.
She is not diabetic and no history of surgery.
【在 M****a 的大作中提到】
: 对于nausea，很多医生都会先开zofran，不管用才开reglan，除非觉得病人的GI
: motility有问题。这个病人吃了半年的reglan，GI motility的问题应该首先排除。做
: 过的workup里面有没有upper GI studies还有gastric emptying study？病人有没有糖
: 尿病？GERD做过手术没有？手术后有没有并发症？做过其他GI手术没有？
|
A*******s
发帖数: 9638 | 12 Nothing was checked that day but she got an order for labs.
【在 y**j 的大作中提到】
: Any elytes abnormality? Hyponatremia?
|
A*******s
发帖数: 9638 | 13 She had Vit b12 checked before and was normal.
【在 c****l 的大作中提到】
: I like to check if there is any vitamin defeciency such as B12.
|
y**j
发帖数: 10 | 14 Results back yet? DDx would be broad from the limited info you provided. I
would like to do a thorough H&P instead of guessing on it based on limited
info before I order any further testings. What else does neuro exam show?
【在 A*******s 的大作中提到】
: Nothing was checked that day but she got an order for labs.
|
A*******s
发帖数: 9638 | 15 Read my question carefully. You are supposed to give the right advice
yesterday. The PCP ordered some lab work but it takes time and possibly not
relevant.
What if you are her gynecologist? How about a psychiatrist?
【在 y**j 的大作中提到】
: Results back yet? DDx would be broad from the limited info you provided. I
: would like to do a thorough H&P instead of guessing on it based on limited
: info before I order any further testings. What else does neuro exam show?
|
d**o
发帖数: 618 | 16 ok ... that sounds tough indeed, more details warranted.
Since ataxia is the only cue now, can you describe the ataxia in more detail
? Is it symmetric? Is knee DTR normal? How about dorsiflexion, finger-to-
nose, babinski, romberg? Or are you saying neuro exam is all normal except
for ataxia??
And on HPI, any vision/hearing loss? memory loss? head trauma?
And on ROS, any hepatomegaly? jaundice? copper/lead exposure? |
d**o
发帖数: 618 | 17 Agree that we cannot ask for labs for now, but given that nausea and ataxia
are the main complaints, I'd argue a thorough focus exam on GI and neuro is
warranted no matter what the specialty is ...
【在 A*******s 的大作中提到】
: Read my question carefully. You are supposed to give the right advice
: yesterday. The PCP ordered some lab work but it takes time and possibly not
: relevant.
: What if you are her gynecologist? How about a psychiatrist?
|
A*******s
发帖数: 9638 | 18 我觉得大家把问题想复杂了，否则这个问题在周末结束之前不会有答案。
你同意ataxia是Reglan的副作用吗？ 这个ataxia实际上是什么？你是她的PCP会怎么做？
ataxia
is
【在 d**o 的大作中提到】
: Agree that we cannot ask for labs for now, but given that nausea and ataxia
: are the main complaints, I'd argue a thorough focus exam on GI and neuro is
: warranted no matter what the specialty is ...
|
d******d
发帖数: 192 | 19 纸上谈兵啊，并没有太多的临床经验。但学step1 时，记得Reglan会cause Parkinson
effect，所以我猜ataxia是tardive dyskinesia 之类的问题？只是不知道立刻停用会
不会引发别的withdraw问题，还有停了Reglan应该换别的药控制她的症状吧？
做？
【在 A*******s 的大作中提到】
: 我觉得大家把问题想复杂了，否则这个问题在周末结束之前不会有答案。
: 你同意ataxia是Reglan的副作用吗？ 这个ataxia实际上是什么？你是她的PCP会怎么做？
:
: ataxia
: is
|
d**o
发帖数: 618 | 20 I guess you're right, sudden withdrawal could cause rebound dopamine effect
if we take haloperidol as reference. Still, if it's tardive dyskinesia it'd
be irreversible anyway, so I wonder how much difference tapering makes if it
has been that chronic.
Parkinson
【在 d******d 的大作中提到】
: 纸上谈兵啊，并没有太多的临床经验。但学step1 时，记得Reglan会cause Parkinson
: effect，所以我猜ataxia是tardive dyskinesia 之类的问题？只是不知道立刻停用会
: 不会引发别的withdraw问题，还有停了Reglan应该换别的药控制她的症状吧？
:
: 做？
|
|
|
D*********t
发帖数: 140 | 21 It seems that the patient presented with some extrapyramidal symptoms caused
by Reglan. So the ataxia in this patient might be tardive dyskinasia or
Parkinson like symptoms..
But D/C Reglan abruptly may be not good due to concern of withdrawal
symptoms. I would reduce dose to 5 mg and add diphenhydramine.
【在 A*******s 的大作中提到】
: 池大你给发啊， lol
: A 50 yrs old WF with a history of GERD and intractable nausea developed
: ataxia for the past 1 month. She has been been on Reglan 10 mg po qid for
: the past 6 months. This morning, she was seen by her PCP who immediately
: realized it is reglan side effect. So the PCP discontinued the reglan.
: You happened to be her doctor for other reasons and saw her on same day.
: What do you do differently?
|
d**o
发帖数: 618 | 22 http://tinyurl.com/grguf
Sounds like PCP should not prescribe more than 3 months to begin with.
Or, if her nausea had been really bad and was improved with the drug,
and ataxia is mild, then I might propose not to stop it. Maybe just reduce
dose to maintain the antiemetic effect. Tardive dyskinesia that I have
seen in a pt isn't as scary as it's on textbooks.
BTW I'm not convinced that NPH is ruled out yet since ataxia is often the
first symptom of NPH triad. |
A*******s
发帖数: 9638 | 23 I am very impressed by Dr.Lee's Externs: Doublemd and Dreadnaught. You two
deserve the 包子。
看来周末quiz还得等周末解决，池大发包子吧，呵呵
这个问题在我们平时practice非常常见，Reglan是一些医生的常用药，对某些
intractable nausea非常有效。 这个病人显然是出现了Parkinsonism，NPH可以是DDx,
但这个病人应该首先考虑reglan引起的parkinsonism。
PCP的诊断是对的，但他的错误是停药。 突然停药可以引起或加重tardive dyskinesia
（TD). TD可以是irreversible，而且不可治愈。 TD是practice中经常引起法律纠纷的
一种disability，所以应该尽量避免。
正确做法是taper off。 我们有很多精神科医生，像benpu，stardust，etc， 你们应
该是处理neuroleptics副作用的专家，这里讲的原则同样适用于所有neuroleptics 引
起的TD, 所有医生都应该注意这个副作用。 |
h*******r
发帖数: 182 | 24 Ataxia is incoordination of movement, while TD is involuntary movement. If
she really has one month of ataxia plus nausea, we have to think about other
DDx than drug-induced TD. If she is having TD and no "ataxia", then PCP is
having trouble for giving pt long-term treatment of Reglan and sudden
withdrawal.
【在 A*******s 的大作中提到】
: 池大你给发啊， lol
: A 50 yrs old WF with a history of GERD and intractable nausea developed
: ataxia for the past 1 month. She has been been on Reglan 10 mg po qid for
: the past 6 months. This morning, she was seen by her PCP who immediately
: realized it is reglan side effect. So the PCP discontinued the reglan.
: You happened to be her doctor for other reasons and saw her on same day.
: What do you do differently?
|
A*******s
发帖数: 9638 | 25 You are right about the definition. This patient had no signs of TD at the
time of discontinuation of Reglan, however, he is at the risk of developing
TD if Reglan is discontinued without tapering.
Although I have seen a lot of cases of sudden withdrawal of Reglan during my
practice without serious consequences, the right thing to do is what I have
said above. Drug induced TD is a common cause to initiate a lawsuit.
other
is
【在 h*******r 的大作中提到】
: Ataxia is incoordination of movement, while TD is involuntary movement. If
: she really has one month of ataxia plus nausea, we have to think about other
: DDx than drug-induced TD. If she is having TD and no "ataxia", then PCP is
: having trouble for giving pt long-term treatment of Reglan and sudden
: withdrawal.
|
d**o
发帖数: 618 | 26 I get your point that sudden withdrawal is a problem, and thank you much for
teaching us this. What I don't get, and huskystar also seems to wonder, is
why you (and PCP) decided that the ataxia is side effect of Reglan. It
should
be obvious on physical exam whether the "ataxia" is cerebellar/sensory or
Parkinsonian. That's why I asked about PE details. Are you suggesting that
cerebellar/sensory ataxia can still be an atypical side effect of Reglan?
developing
my
have
【在 A*******s 的大作中提到】
: You are right about the definition. This patient had no signs of TD at the
: time of discontinuation of Reglan, however, he is at the risk of developing
: TD if Reglan is discontinued without tapering.
: Although I have seen a lot of cases of sudden withdrawal of Reglan during my
: practice without serious consequences, the right thing to do is what I have
: said above. Drug induced TD is a common cause to initiate a lawsuit.
:
: other
: is
|
M***D
发帖数: 249 | 27 Yes, Reglan can cause both TD and ataxia, especially in children. |
A*******s
发帖数: 9638 | 28 No, it could be difficult to differentiate cerebellar ataxia and
parkinsonism clinically. But why we differentiate them? SCA-2 or 3 can
overlap with parkinsonism.
for
【在 d**o 的大作中提到】
: I get your point that sudden withdrawal is a problem, and thank you much for
: teaching us this. What I don't get, and huskystar also seems to wonder, is
: why you (and PCP) decided that the ataxia is side effect of Reglan. It
: should
: be obvious on physical exam whether the "ataxia" is cerebellar/sensory or
: Parkinsonian. That's why I asked about PE details. Are you suggesting that
: cerebellar/sensory ataxia can still be an atypical side effect of Reglan?
:
: developing
: my
|
d*****x
发帖数: 96 | 29 I was very busy but was interested in this case. I did a little research and
found some information below which may be useful.
http://www.uptodate.com/contents/tardive-dyskinesia-prevention-
"Discontinuation of metoclopramide treatment — Metoclopramide is used
primarily as an antiemetic agent and/or as a prokinetic agent for the
treatment of gastroparesis. It should be stopped immediately if the
diagnosis of TD is made, and alternative treatments of the gastrointestinal
symptoms should be used. As a preventive measure, metoclopramide should not
be used continuously for longer than 12 weeks."
At least for TD side effects, Reglan should immediately be stopped and
alternative treatments should be started.
Actually for Reglan, FDA recommend to use for less than 12 weeks, but still
over 30% patients are taking Reglan for more than 12 weeks.
There is also a link :
http://www.youhavealawyer.com/reglan/metoclopramide-side-effect
In 2009, the FDA began requiring the makers of Reglan drugs containing
metoclopramide to place a “black box” Tardive Dyskinesia warning.
The website mentioned that the manufacturers gave wrong information that the
incidence of tardive dyskinesia from Reglan side effects is only about 0.2%
, but later researchers indicate that the true incidence rate is likely more
than 20% when used long-term or at high doses and elderly can experience
the Reglan Tardive Dyskinesia problems at much lower doses.
As A++ just mentioned, there are metoclopramide lawsuits in the USA, but
take a look at the link below:
http://www.youhavealawyer.com/reglan/
The Reglan lawyers at Saiontz & Kirk, P.A. are no longer reviewing potential
lawsuits for users of Metoclopramide drugs who have developed Tardive
Dyskinesia, Tardive Distonia or other related conditions.
Reglan lawsuits were reviewed as a result of the drug makers’ failure to
warn potential users and the medical community about the risk of Tardive
Dyskinesia side effets.
Although the information above is from a lawyer's website, it seems patients
cannot even file the the metoclopramide lawsuit.No lawyers would take such
cases.
I will check if more information is available. |
d*****x
发帖数: 96 | 30 Another link:
http://www.findtherightreglanlawyer.com/time-is-running-out-to-
If some people don’t file a Reglan lawsuit by February of 2011, they will
never be able to!
So now doctors don't need to worry about it at all. |
