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Medication

Medication Summary

Medications, most of which address fatigue, have been used with only partial success in patients with postpolio syndrome (PPS). Contradictory information is reported on the use of antivirals.

Some authors have found no significant improvement with antivirals as compared with placebo. Amantadine may act to release dopamine from dopaminergic terminals and other central sites, but it has been studied in the treatment of fatigue in PPS patients and has not been shown to be beneficial.^[48]Corticosteroids, such as high-dose prednisone, have been studied, but with no good results.^[49]Modafinil has been studied for fatigue in PPS patients and has not shown to be beneficial.^{[50, 51]}

A Cochrane review of the different treatments for PPS concluded that intravenous immunoglobulin, lamotrigine, muscle strengthening exercises, and static magnetic fields may be beneficial but need further investigation.^[52]

Neither controlled studies nor meta-analyses have shown that, when compared with placebo, pyridostigmine improves fatigue, muscle strength or function, or pain in patients with postpolio syndrome. However, a small noncontrolled trial did report that the drug improved fatigue in some patients.^[53]

A prospective study by Östlund et al indicated that patients with PPS who respond to intravenous immunoglobulin therapy tend prior to treatment to have reduced physical function, muscle atrophy in the lower extremities, and greater fatigue and pain levels, as well as a visual analogue scale score above 20. The study, which included 124 patients, found that those who did not respond to the treatment tended to have good physical function, less muscle atrophy in the lower extremities, low pain and fatigue levels, and good mental health.^[54]

A study by Bertolasi et al found that a single 5-day course of intravenous immunoglobulin did not cause significant changes in fatigue, muscle strength, or pain in patients with PPS. However, health-related quality of life associated with mental activity was improved.^[55]

Class Summary

Some authors have reported that one of the mechanisms for production of fatigue may be related to neuromuscular junction transmission deficits; however, treatment with anticholinesterases has been successful in only half of the cases. This low success rate has been attributed to the variety of neuromuscular junction defects believed to be present in postpolio syndrome. The mechanism of response to anticholinesterases also is unclear because some patients experience improvement in muscular strength, rather than improvement in fatigability.

A multicenter, randomized, double-blinded, placebo-controlled trial of a 6-month course of pyridostigmine 60 mg 3 times per day in 126 postpolio syndrome patients showed no significant differences between pyridostigmine and placebo-treated postpolio syndrome patients on measures of quality of life, isometric strength, fatigue, and serum insulinlike growth factor levels.^[56]

Pyridostigmine (Mestinon)

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Acts in smooth muscle, the CNS, and secretory glands where it blocks action of acetylcholine at parasympathetic sites and facilitates transmission of impulses across the myoneural junction.

Class Summary

Modulate activity of immune system.^{[57, 55]}

Immunoglobulin intravenous (Gammagard, Sandoglobulin)

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Intravenous immunoglobulin has been recently studied in the treatment of symptoms related to postpolio syndrome. Results show that it could be a supportive treatment option for subgroups of patients with postpolio syndrome. Further studies are needed to investigate this in more detail.

Features that may be relevant to its efficacy include neutralization of circulating myelin antibodies through anti-idiotypic antibodies; down-regulation of proinflammatory cytokines, including IFN-gamma; blockade of Fc receptors on macrophages; suppression of inducer T and B cells and augmentation of suppressor T cells; blockade of the complement cascade; promotion of remyelination; 10% increase in CSF IgG.

Class Summary

Lamotrigine may reduce morbidity of the disease.^[58]

Lamotrigine (Lamictal)

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Some preliminary studies suggest the efficacy of lamotrigine in enhancing the quality of life and symptoms of patients with postpolio syndrome. Further studies are needed.

Inhibits release of glutamate and inhibits voltage-sensitive sodium channels, leading to stabilization of neuronal membrane.

Follow-up

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Author

Divakara Kedlaya, MBBS Locum Provider, Physical Medicine and Rehabilitation and Pain Management

Divakara Kedlaya, MBBS is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Kat Kolaski, MD Assistant Professor, Departments of Orthopedic Surgery and Pediatrics, Wake Forest University School of Medicine

Kat Kolaski, MD is a member of the following medical societies: American Academy for Cerebral Palsy and Developmental Medicine, American Academy of Physical Medicine and Rehabilitation

Disclosure: Nothing to disclose.

Chief Editor

Stephen Kishner, MD, MHA Clinical Professor, Louisiana State University School of Medicine in New Orleans

Stephen Kishner, MD, MHA is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine

Disclosure: Nothing to disclose.

Acknowledgements

Martin K Childers, DO, PhD Professor, Department of Neurology, Wake Forest University School of Medicine; Professor, Rehabilitation Program, Institute for Regenerative Medicine, Wake Forest Baptist Medical Center

Martin K Childers, DO, PhD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Congress of Rehabilitation Medicine, American Osteopathic Association, Christian Medical & Dental Society, and Federation of American Societies for Experimental Biology

Disclosure: Allergan pharma Consulting fee Consulting

Gerald J Herbison, MD Professor, Department of Rehabilitation Medicine, Jefferson Medical College, Thomas Jefferson University

Disclosure: Nothing to disclose.

Flor M Muñiz, MD Assistant Professor, Department of Physical Medicine and Rehabilitation, McMaster University, Hamilton, Ontario

Flor M Muñiz, MD is a member of the following medical societies: American Medical Association, Canadian Association of Physical Medicine and Rehabilitation, and Canadian Medical Association

Disclosure: Nothing to disclose.

Postpolio Syndrome Medication

Medication Summary

Anticholinesterases

Class Summary

Pyridostigmine (Mestinon)

Pyridostigmine (Mestinon)

Immunoglobulins

Class Summary

Immunoglobulin intravenous (Gammagard, Sandoglobulin)

Immunoglobulin intravenous (Gammagard, Sandoglobulin)

Anticonvulsant agents

Class Summary

Lamotrigine (Lamictal)

Lamotrigine (Lamictal)

Postpolio Syndrome Medication

Medication Summary

Anticholinesterases

Class Summary

Pyridostigmine (Mestinon)

Pyridostigmine (Mestinon)

Immunoglobulins

Class Summary

Immunoglobulin intravenous (Gammagard, Sandoglobulin)

Immunoglobulin intravenous (Gammagard, Sandoglobulin)

Anticonvulsant agents

Class Summary

Lamotrigine (Lamictal)

Lamotrigine (Lamictal)

References

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