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Effects of prophylactic anticholinergic medications to decrease extrapyramidal side effects in patients taking acute
Ryan S D'Souza1,2, Christopher Mercogliano1, Elizabeth Ojukwu3
1Department of Medicine, Reading Health System, West Reading, Pennsylvania, USA.
Prophylactic diphenhydramine effectively reduces extrapyramidal symptoms when given with bolus antiemetics for acute migraine. However, it increases sedation and is not beneficial with infused antiemetics, making infusion without prophylaxis the preferred strategy.
Area of Science:
- Neurology
- Clinical Pharmacology
Background:
- Dopamine D2 antagonist antiemetics are used for acute migraine.
- Extrapyramidal symptoms (EPS) are a potential side effect.
- Prophylactic anticholinergic medications may mitigate EPS.
Purpose of the Study:
- To evaluate the effectiveness of prophylactic anticholinergic medications in reducing EPS.
- To compare outcomes based on antiemetic administration method (bolus vs. infusion).
Main Methods:
- Systematic review and meta-analysis of randomized controlled trials.
- Searched PubMed, Cochrane, Embase, Web of Science, Scopus through March 2017.
- Included trials comparing anticholinergics (diphenhydramine) or placebo with D2 antagonist antiemetics for acute migraine.
Main Results:
- Four trials (737 patients) met inclusion criteria.
- Diphenhydramine significantly reduced EPS with 2-min antiemetic boluses (OR 0.42).
- No significant difference in EPS with 15-min antiemetic infusions (OR 1.06).
- Lowest EPS incidence (9.8%) observed with 15-min infusion without diphenhydramine.
- Diphenhydramine significantly increased sedation (OR 2.01).
Conclusions:
- Prophylactic diphenhydramine reduces EPS with bolus D2 antagonist antiemetics.
- Diphenhydramine does not reduce EPS when antiemetics are infused.
- Due to increased sedation, 15-min antiemetic infusion without prophylaxis is the most effective strategy.
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