23 - Parkinson Disease

Question 1

If > 60 yo, can start _____ as first line

Answer 1

levodopa

Question 2

If < 60 yo, can start _____ ____ as first line

Answer 2

dopamine agonists

Question 3

meds that provide the most benefit increase _____ levels in the brain

Answer 3

dopamine

Question 4

Exclude drugs that can induce parkinsonism such as what drugs?

Answer 4

-FGAs, SGAs and central dopamine-blocking antiemetics (ex. metoclopramide and prochlorperazine)

Question 5

non-pharms for PD ?

Answer 5

exercise, speech therapist or physical therapist may help. some benefit from surgery

Question 6

MOA of levodopa

Answer 6

converted to dopamine within presynaptic dopaminergic neurons

Question 7

Why is levodopa combined with carbidopa or benserazide?

Answer 7

They are DOPA decarboxylase inhibitors
-They inhibit peripheral transformation to dopamine, thus enhancing distribution to the brain, reducing amount of Levodopa required, minimizing s/e such as n/v

Question 8

Bromocriptine, Pramipexole, Ropinirole, Pergolide, Rotigotine are all examples of ??

Answer 8

dopamine agonists

Question 9

Place in therapy for dopamine agonists?

Answer 9

as monotherapy in early PD or as adjunct to levodopa in more severe cases

Question 10

What dopamine agonist is not on the market anymore due to cases of serious cardiac problems but still available through SAP ?

Answer 10

Pergolide

Question 11

What dopamine agonist comes as a patch?

Answer 11

Rotigotine

Question 12

Advantage of using dopamine in early or young PD over levodopa?

Answer 12

they have less motor complications than levodopa in the first 5 years

Question 13

Both levodopa and dopamine agonists can cause what side effect ?

Answer 13

daytime sleepiness or sleep attacks (occurs more frequently with dopamine agonists than levodopa)

Question 14

What is a s/e of dopamine agonists?

Answer 14

• hypersexual behavior or gambling problems

- GI s/e, hypotension and psych reactions

Question 15

List 2 MAOB inhibitors

Answer 15

• selegiline

- rasigiline

Question 16

MAOB inhibitors are first line for ___ _____

Answer 16

mild symptoms

Question 17

Which MAOB inhibitor is more potent and for more advanced diseases

Answer 17

rasagiline

Question 18

When do you give MAOB inhibitors?

Answer 18

morning

Question 19

What is amantadine and what is it’s place in therapy?

Answer 19

• NMDA antagonist
• mild-mod improvement and improves levodopa-induced dyskinesias in the later stages of the disease
• don’t use with cognitive deficits

Question 20

Rare but notable s/e of amantadine?

Answer 20

levidoreticulitus - blue/skin mainly in lower extremeties

Question 21

Trihexyphenidyl, benztropine, ethopropazine, and procyclidine are examples of _______ used in PD

Answer 21

anticholinergics

Question 22

What do anticholinergics help most with?

Answer 22

tremor

Question 23

s/e of anticholinergics

Answer 23

dry eyes/mouth, urinary retention, constipation

Question 24

Why do you give COMT inhibitors with levodopa?

Answer 24

• COMT is an enzyme that helps metabolize levodopa

- give a COMT inhibitor to increase levels of levodopa and therefore can use lower doses and minimize s/e

Question 25

List 2 examples of COMT inhibitors

Answer 25

• entacapone

- tolcapone

Question 26

_____ is a COMT inhibitor that was approved by HC but bc of hepatotoxicity is now only available through SAP

Answer 26

tolcapone

Question 27

_____ is a COMT inhibitor not associated with liver toxicity but can cause diarrhea and orange/brown urine

Answer 27

entacapone

Question 28

Tx of Non-Motor Issues:

Options for depression?

Answer 28

SSRIs or TCAs (use with caution)

Question 29

Tx of Non-Motor Issues:

Options for Psychosis and Dementia?

Answer 29

• withdraw anticholinergics, then selegiline, rasagiline, then everything until only levodopa remains
• Can sometimes use antipsychotics as long as PD symptoms are still managed

Question 30

Tx of Non-Motor Issues:
Options for Psychosis and Dementia:

What SGA appears to have lowest risk of reducing control of movement disorders?

Answer 30

clozapine

Question 31

Tx of Non-Motor Issues:
Options for Psychosis and Dementia:

What SGA do we try first before clozapine to avoid blood monitoring?

Answer 31

quetiapine has no evidence but often tried first to avoid blood monitoring

Question 32

Tx of Non-Motor Issues:
Options for Psychosis and Dementia:

If they have deterioration in motor function from adding antipsychotics, what else can we add on?

Answer 32

ChEi (ex. donepezil, rivastigmine, galantamine)

Question 33

Tx of Non-Motor Issues:

Treatment of autonomic dysfunction?

Answer 33

• increase salt and H20 intake and avoid alcohol to increase BP
• if that doesn’t work, add domperidone, midodrine and/or fludrocortisone

Question 34

Tx of Non-Motor Issues:

Tx of urinary incontinence?

Answer 34

anticholinergics

Question 35

What can occur if PD drugs are abruptly d/c?

Answer 35

NMS

Question 36

What are 2 risk factors for NMS?

Answer 36

• dehydration

- hyponatremia