23 - Parkinson Disease Flashcards
If > 60 yo, can start _____ as first line
levodopa
If < 60 yo, can start _____ ____ as first line
dopamine agonists
meds that provide the most benefit increase _____ levels in the brain
dopamine
Exclude drugs that can induce parkinsonism such as what drugs?
-FGAs, SGAs and central dopamine-blocking antiemetics (ex. metoclopramide and prochlorperazine)
non-pharms for PD ?
exercise, speech therapist or physical therapist may help. some benefit from surgery
MOA of levodopa
converted to dopamine within presynaptic dopaminergic neurons
Why is levodopa combined with carbidopa or benserazide?
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
Bromocriptine, Pramipexole, Ropinirole, Pergolide, Rotigotine are all examples of ??
dopamine agonists
Place in therapy for dopamine agonists?
as monotherapy in early PD or as adjunct to levodopa in more severe cases
What dopamine agonist is not on the market anymore due to cases of serious cardiac problems but still available through SAP ?
Pergolide
What dopamine agonist comes as a patch?
Rotigotine
Advantage of using dopamine in early or young PD over levodopa?
they have less motor complications than levodopa in the first 5 years
Both levodopa and dopamine agonists can cause what side effect ?
daytime sleepiness or sleep attacks (occurs more frequently with dopamine agonists than levodopa)
What is a s/e of dopamine agonists?
- hypersexual behavior or gambling problems
- GI s/e, hypotension and psych reactions
List 2 MAOB inhibitors
- selegiline
- rasigiline
MAOB inhibitors are first line for ___ _____
mild symptoms
Which MAOB inhibitor is more potent and for more advanced diseases
rasagiline
When do you give MAOB inhibitors?
morning
What is amantadine and what is it’s place in therapy?
- NMDA antagonist
- mild-mod improvement and improves levodopa-induced dyskinesias in the later stages of the disease
- don’t use with cognitive deficits
Rare but notable s/e of amantadine?
levidoreticulitus - blue/skin mainly in lower extremeties
Trihexyphenidyl, benztropine, ethopropazine, and procyclidine are examples of _______ used in PD
anticholinergics
What do anticholinergics help most with?
tremor
s/e of anticholinergics
dry eyes/mouth, urinary retention, constipation
Why do you give COMT inhibitors with levodopa?
- 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
List 2 examples of COMT inhibitors
- entacapone
- tolcapone
_____ is a COMT inhibitor that was approved by HC but bc of hepatotoxicity is now only available through SAP
tolcapone
_____ is a COMT inhibitor not associated with liver toxicity but can cause diarrhea and orange/brown urine
entacapone
Tx of Non-Motor Issues:
Options for depression?
SSRIs or TCAs (use with caution)
Tx of Non-Motor Issues:
Options for Psychosis and Dementia?
- withdraw anticholinergics, then selegiline, rasagiline, then everything until only levodopa remains
- Can sometimes use antipsychotics as long as PD symptoms are still managed
Tx of Non-Motor Issues:
Options for Psychosis and Dementia:
What SGA appears to have lowest risk of reducing control of movement disorders?
clozapine
Tx of Non-Motor Issues:
Options for Psychosis and Dementia:
What SGA do we try first before clozapine to avoid blood monitoring?
quetiapine has no evidence but often tried first to avoid blood monitoring
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?
ChEi (ex. donepezil, rivastigmine, galantamine)
Tx of Non-Motor Issues:
Treatment of autonomic dysfunction?
- increase salt and H20 intake and avoid alcohol to increase BP
- if that doesn’t work, add domperidone, midodrine and/or fludrocortisone
Tx of Non-Motor Issues:
Tx of urinary incontinence?
anticholinergics
What can occur if PD drugs are abruptly d/c?
NMS
What are 2 risk factors for NMS?
- dehydration
- hyponatremia
