43 - PD Campbell

Question 1

motor symptoms (4)

Answer 1

tremor
bradykinesia
rigidity
Parkinsonian gait

Question 2

non-motor symptoms

Answer 2

anxiety, depression
constipation
dementia
insomnia
orthostatic hypotension
psychosis/delirium
sexual dysfunction

Question 3

initial treatment - first line

• rule out ___ PD
• dopamine ___
• dopamine ___
• MAO-B inhibitor

Answer 3

drug induced
precursor
agonist

Question 4

initial treatment - second line

• ___ inhibitors
• amantadine

Answer 4

COMT

Question 5

treatment initiation

• for most, initiate ___
• dopamine ___ may be used as initial treatment if < 60 years old and higher risk of dyskinesia

efficacy with motor symptoms:
___ / ___ > DA > MAO-B inh

Answer 5

levodopa
agonists
levodopa/carbidopa

Question 6

avoid dopamine agonists if
- age > ___
- history of ICD
- ___ impairment
- excessive daytime sleepiness
- hallucinations

ICD = impulse control disorder

Answer 6

70
cognitive

Question 7

dopamine precursor

levodopa/carbidopa
- first line, gold standard for motor symptoms
- adjunct with dopamine agonists and other agents
- SE: N/V, LD motor fluctuations/ ___ , hallucinations

clinical pearls
- increase absorption on empty stomach but food helps with N/V
- starting dose: ___ / ___ mg CD/LD PO BID-TID with meals
- frequency can increase as needed ( ___ - ___ x/day) or switch to XR

Answer 7

• dyskinesias
• 25/100
• 5-6x

Question 8

Dopamine Agonists - non-ergot

4 drugs
- first line for initial PD
- minimize LD motor fluctuations

SE
- N/V, sudden ___ , hallucinations, ___, edema, orthostatic hypotension, $$$$

starting doses
- pramipexole IR 0.125 mg TID, ER 0.375 mg
- ropinirole IR 0.25 mg TID, ER 2 mg
- rotigotine 2 mg ___
- apopmorphine 2 mg SQ injection

advantages
- fewer ___ fluctuations
- long acting formulations

Answer 8

pramipexole, ropinirole, rotigotine, apomorphine
- sleep, ICD
- patch
- motor

ICD = impulse control disorder

Question 9

Dopamine Agonists - ergot

2 drugs
rarely used due to toxicity

Answer 9

bromocriptine
cabergoline

Question 10

MAO-B inhibitors

3 drugs
- first line for mild symptoms
- second line ___ therapy
- manage LD motor fluctuations
- adjunctive for PD depression

SE
- N/V, headache, insominia ( ___)

starting doses
- rasagiline 0.5 mg PO daily
- selegiline 5 mg BID
- safinamide 50 mg PO daily

clinical pearls
- dietary resrictions: ___ rich foods
- risk of ___ syndrome (antidepressants, dextromethorphan, serotenergic opiods)

Answer 10

rasagiline, selegiline, safinamide
- adjunct
- selegiline
- tyramine
- serotonergic

Question 11

COMT inhibitors

3 drugs
- in combo to manage symptom ___

SE
- N/V
- brown/orange urine discoloration ( ___ )
- hepatotoxicity ( ___ use limiting side effect)

clinical pearls
- no benefit in ___ PD in additon to CD/LD

starting doses
- entacapone 200 mg
- tolcapone 100 mg TID
- opicapone 50 mg QHS

Answer 11

entacapone, opicapone, tolcapone
- entacapone
- tolcapone
- early

Question 12

Amantadine

amantadine ( ___ )
- manage of LD motor fluctuations
- modest effect in controlling motor symptoms, but rarely used as monotherpy

SE
- ___
- confusion/hallucinations
- livedo reticularis

clinical pearls
- utility limited due to ___ SE
- usually reserved CD/LD peak dose dyskinesias

starting dose: 100 mg BID

Answer 12

Symmetrel
insomnia
cognitive

Question 13

anticholinergics

benztropine ( ___ ) and ___ (Artane)
- management of ___ dominant symptoms in patients ___ 65 years old

SE
- confusion/dementia
- blurry vision
- urinary retention
- dry mouth
- constipation

starting doses
- benztropine 0.5 mg QHS
- trihexylphenidyl 1 mg daily

clinical pearls
- use limited by confusion and anti-muscarinic side effects
- avoid if ___ 65 years old

Answer 13

Cogentin, trihexyphenidyl
- tremor, <
- >

cant see, cant pee, cant spit, cant shit

Question 14

initial first-line pharmacotherapy

Dopamine Agonist

pros
- once daily dosing formulations
- better tolerated by ___ patients
- limited ___ fluctuations

cons
- expensive
- less symptomatic benefit compared to __ / __
- many adverse effects

who
- age < ___ and highers risk of dyskinesias

avoid as initial treatment if:
- age >. ___ years
- history of ___
- cognitive impairment
- excessive daytime ___
- hallucinations

Answer 14

• younger
• motor
• CD/LD
• 60
• 70
• ICD
• sleepiness

Question 15

carbidopa/levodopa

pros
- ___ standard due to symptomatic beneft
- cost
- variety of dosage forms

cons
- ___ fluctuations
- dosing frequency (can be over 3x/day)

who
- most

Answer 15

• gold
• motor

Question 16

MAO-B

pros
- generally well tolerated
- delays onset of ___ fluctuations

cons
- least effective first line agent against motor symptoms
- dietary restrictions lead and risk of ___ syndrome

who
- minor symptoms
- ___ risk of motor fluctuations

Answer 16

• motor
• least
• serotonin
• higher

Question 17

LD Motor Fluctuations

1) wearing off - ___ next dosing interval, signs of ___ symptoms
2) freezing - inability to move due to fluctuating ___ levels
3) delayed onset - therapeutic benefits ___
4) peak dose dyskinesias - involuntary body movement caused by ___ DA levels

Answer 17

• before, motor
• DA
• delayed
• high

Question 18

LD Motor Fluctuations

wearing off
- increase ___ / ___ dose or frequency
- add DA ___ , ___ inhibitor , ___ inhibitor
- ___ CD/LD

freezing
- increase ___ / ___ dose or frequency
- add DA agonist ( ___)
- add ODT CD/LD

Answer 18

• CD/LD
• agonist, MAO, COMT
• XR
• CD/LD
• apomorphine

Question 19

delayed onset
- take CD/LD on ___ stomach
- ___ CD/LD
- avoid ___ and ___ CD/LD

peak-dose dyskinesias
- add ___
- decrease dose of ___ or ___ / ___

Answer 19

• empty
• ODT
• CR, XR
• amantadine
• DA, CD/LA

Question 20

treatment of non-motor symptoms

constipation
- evaluate for medications causing constipation
- increase fluid intake
- stool softeners/laxatives or probiotics

insomnia
- melatonin
- avoid ___

orthostatic hypotension
- ___ and ___

Answer 20

• benzodiazepines
• midodrine, droxidopa