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Pharmacy Pre-Reg 2020/2021 > Chapter 4 - Movement Disorders > Flashcards

Chapter 4 - Movement Disorders Flashcards

1
Q

How is pain managed in cerebral palsy?

A

Pain related to spasticity or muscle spasm:
Baclofen
Diazepam

Other causes of pain
Usual analgesic ladder

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2
Q

How is drooling managed in cerebral palsy?

A

Give an antimuscarinic e.g.
Glycopyronium
Hyoscine

If this doesn’t work
Botulinum toxin type A can be administered into the salivary glands

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3
Q

What should patients with cerebral palsy be given to protect their bones?

A

Vitamin D and calcium

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4
Q

What symptoms should patients be warned of when taking Botulinum toxin type A?

A

Swallowing or breathing difficulties

Breathing difficulties

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5
Q

What is motor neurone disease?

A

A neurodegenerative condition affecting the brains and spinal chord

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6
Q

List some symptoms of motor neurone disease

A 
Muscle weakness 
Muscle pain
Muscle stiffness
Muscle wasting
Cognitive decline 
Decline in respiratory function
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7
Q

What is amyotrophic lateral sclerosis and what can be used to extend life?

A

The most common form of motor neurone disease

Riluzole can be used to extend life

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8
Q

What is the aim of drug therapy in motor neurone disease?

A

To manage symptoms (MND is incurable)

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9
Q

What can be given to manage the muscular symptoms in motor neurone disease?

A

First line - quinine
Second line - baclofen
Alternatives - gabapentin, tizanidine, dantrolene

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10
Q

What are the options for saliva problems in motor neurone disease?

A

Glycopyronium
Botulinium toxin type A

If saliva is this
Carbocisteine
Nebuliser
Humidifier

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11
Q

Can glycopyronium be given to patients with motor neurone disease and cognitive impairment?

A

Yes

Glycopyronium bromide has the advantage of having few CNS side effects

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12
Q

What can be used to manage respiratory symptoms in motor neurone disease?

A

Opioids

Benzodiazepines if there is co-existing anxiety

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13
Q

When do patients need to inform the DVLA about having Parkinson’s disease?

A

At the point of diagnosis

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14
Q

What are some motor symptoms associated with Parkinson’s disease?

A 
Bradykinesia
Rigidity 
Postural instability (increased falls)
Freezing
Shuffling
Tremor
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15
Q

What are some non-motor symptoms associated with Parkinson’s disease?

A 
Dementia 
Depression 
Urinary incontinence 
Constipation 
Pain
Sleep disturbances 
Dysphagia
Speech and language changes
Weight loss
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16
Q

Which analgesic shouldn’t be used in Parkinson’s disease?

A

Tramadol - may exacerbate symptoms

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17
Q

How should dementia associated with Parkinson’s disease be managed?

A

AChE Inhibitors/memantine

Don’t use antipsychotics - can cause EPSEs and worsen Parkinson’s symptoms

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18
Q

What is off time in Parkinson’s disease?

A

Amount of time in the day the patient experiences symptoms of Parkinson’s

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19
Q

What is on time in Parkinson’s disease?

A

Amount of time in the day the patient does not experience the symptoms of Parkinson’s

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20
Q

What are the 3 main mechanisms of anti-Parkinson’s drugs?

A

Give a dopamine precursor
Give a dopamine receptor agonist
Reduce the breakdown of dopamine

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21
Q

What is the first line option if symptoms of Parkinson’s are affecting QoL in the elderly?

A

Levodopa combination

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22
Q

What can levodopa be combined with and what is the brand name of these combinations?

A

Dopa decarboxylase inhibitors

Sinemet
Levodopa + carbidopa (co-careldopa)

Madopar
Levodopa + benserazide (co-benledopa)

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23
Q

Why are dopa decarboxylase inhibitors given alongside levodopa?

A

Then don’t cross the BBB
So they block the conversion of levodopa in the periphery, but not in the brain

Therefore there are less peripheral side effects e.g. nausea, arrhythmia, BP changes

And levodopa can be initiated at a lower dose

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24
Q

What is the first line option if symptoms of Parkinson’s are not affecting QoL in the elderly?

A

Either:
Levodopa
Non ergot derived dopamine receptor agonist
MOAB inhibitor

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25
Q

What is the mechanism of levodopa?

A

Crosses BBB

Gets converted into dopamine

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26
Q

What is the mechanism of rasagiline?

A

Inhibits the breakdown of dopamine

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27
Q

What is the mechanism of pramiprexole?

A

Dopamine receptor agonist

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28
Q

Why aren’t ergot derived dopamine receptor agonists used?

A

Risk of cardiac and pulmonary fibrosis

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29
Q

Give examples of non-ergot derived dopamine receptor agonists

A

Pramiprexole
Ropinirole
Rotigotine

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30
Q

Why do you need to consider when prescribing ropinirole in the elderly?

A

Clearance is reduced by approx 15%

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31
Q

Which non-ergot derived dopamine receptor agonist comes as a patch?

A

Rotigotine

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32
Q

What are the main adverse effects associated with antiparkinsonian drugs that patients/carers should be warned about?

A

Impulse control disorders
Psychotic symptoms/hallucinations
Excessive daytime sleepiness/sudden onset of sleep

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33
Q

What are the problems associated with levodopa therapy?

A

Motor complications, including:

Hypotension
End of dose deterioration
On off phenomena
Dyskinesia

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34
Q

What are the benefits of levodopa therapy?

A

Improvement of motor symptoms

Reduced ADRs e.g. daytime sleepiness, impulse control disorders, hallucinations

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35
Q

How can the motor complications associated with levodopa be reduced?

A

Use m/r preparation

Adjunct therapy with dopamine receptor agonist, MAON inhibitor or COMT inhibitor

36
Q

What is dyskinesia?

A

Involuntary motor movements?

37
Q

What are the problems associated with dyskinesia?

A

Increased risk of falls, weight loss and depression (although some patients may prefer dyskinesia to the symptoms of Parkinson’s)

38
Q

What is end of dose deterioration associated with levodopa therapy?

A

The levodopa dose loses its effect before the next dose is due

39
Q

What is the on off phenomena associated with levodopa therapy?

A

Levodopa can stop working at any time of the day for any period of time

40
Q

What causes dyskinesia in levodopa therapy?

A

Exposure to high levels of levodopa

41
Q

What are the benefits of dopamine receptor agonists?

A

Less likely to cause motor complications

42
Q

What are the disadvantages of dopamine receptor agonists?

A

Increased risk of excessive sleepiness, impulse control disorders and hallucinations

Less effective at controlling motor symptoms compared to levodopa

43
Q

Why shouldn’t antiparkinsonian drugs be stopped abruptly?

A

Risk of NMS

44
Q

What should be done when patients experience motor fluctuations despite optimal therapy of levodopa?

A

Adjuvant therapy with either:

Non-ergot derived dopamine receptor agonist

MOAB Inhibitor

COMT inhibitor

45
Q

Give an example of a COMT inhibitor

A

Entacapone

46
Q

Other than levodopa, which class of antiparkinsonian drug is associated with the lowest risk of hallucinations, impulse control disorders and excessive sleepiness?

A

MAOB Inhibitors

47
Q

Give an example of a MAOB Inhibitor

A

Rasagiline

Selegiline

48
Q

Which antiparkinsonian drug in particular has hypotension as a side effect?

49
Q

Which antiparkinsonian drugs in particular shouldn’t be used if a patient is on an SSRI and why?

A

MAOB Inhibitor - increased risk of serotonin syndrome

50
Q

Which antiparkinsonian drugs have the highest association with impulse control disorders?

What may be more suitable for these patients?

A

Dopamine receptor agonists

More suitable - MAOB inhibitors

51
Q

Why is entacapone not often used?

A

Risk of hepatotoxicity

LFTs need to be done every 2 weeks

52
Q

Which motor complications associated with levodopa are COMT inhibitors good at helping with?

A

End of dose deterioration - they increase the plasma half life of levodopa

53
Q

Why do COMT inhibitors increase the risk of dyskinesia?

A

They increase the plasma half life of levodopa, therefore reduce the dose of levodopa

54
Q

Why does the dose of levodopa need to be reduced when COMT inhibitors are initiated?

A

COMT inhibitors increase the plasma half life of levodopa

This increases the risk of dyskinesia

55
Q

How is daytime sleepiness and sudden onset of sleep managed in Parkinson’s disease?

A

Modafinil

Remind the patient to inform the DVLA

56
Q

How is postural hypotension managed in Parkinson’s disease?

A

First line - midodrine

Second line - fludrocortisone acetate

57
Q

How is depression managed in Parkinson’s disease?

A

SSRIs (but this may exacerbate motor symptoms e.g. REM sleep disorder, restless legs)

TCAs (but this may increase the risk of falls and cognitive decline)

58
Q

How are hallucinations managed in Parkinson’s disease?

A

If it’s is caused by antiparkinsonian drugs, consider reducing these

Can use quetiapine or clozapine
But avoid all other antipsychotics as these can cause EPSEs and exacerbate the symptoms of Parkinson’s disease

59
Q

How is REM sleep behaviour disorder managed in Parkinson’s disease?

A

Clonazepam or melatonin

60
Q

How is drooling/saliva managed in Parkinson’s disease?

A

Glycopyronium bromide

Botulinum toxin type A

61
Q

How is dementia managed in Parkinson’s disease?

A

AChE inhibitors

Memantine

62
Q

How is nausea managed in Parkinson’s disease?

A

Nausea usually settles over time
It can be reduced by taking medications with food

Can prescribe domperidone
Don’t use metoclopramide or prochlorperazine as these may exacerbate parkinsonism

63
Q

When is apomorphine used in Parkinson’s?

A

In advanced Parkinson’s where there are motor fluctuations

64
Q

How is nausea and vomiting associated with apomorphine managed?

A

Domperidone- start 2-3 days before apomorphine and continue for the shortest duration

65
Q

What monitoring needs to be carried out when apomorphine and domperidone are used and why?

A

ECG - both can cause serious arrhythmias due to QT interval prolongation when used together

66
Q

Does apomorphine have a:

a) rapid or short onset of action
b) short or long duration of action

A

a) rapid

b) short (t1/2 60-90 mins)

67
Q

Is apomorphine given by:

a) IV
b) IM
c) SC

68
Q

Give some examples of impulse control disorders

A

Binge eating
Gambling
Obsessive shopping
Hypersexuality

69
Q

Which antiparkinsonian drug is best at improving motor symptoms and activities of daily living?

70
Q

Which antiparkinsonian drug is associated with the most motor complications?

71
Q

Which antiparkinsonian drug is associated with the most adverse events?

A

Dopamine receptor agonists

72
Q

Madopar contains x parts of levodopa to y parts of benserazide.

What are x and y?

A 
x = 4
y = 1
73
Q

The doses of co-benledopa in the BNF are expressed as which components?

74
Q

What important safety information is associated with antiparkinsonian drugs?

A

Avoid abrupt withdrawal - risk of NMS

Risk of impulse control disorders, excessive sleepiness/sudden onset of sleep, hallucinations

75
Q

What side effects are associated with levodopa?

A 
Movement disorders 
Impulse control disorders 
Hallucinations 
Daytime sleepiness/sudden onset of sleepiness 
Nausea
Postural hypotension 
Red/brown urine
76
Q

Are different co-beneldopa formulations interchangeable?

A

No

If you go from i/r to m/r, the dose should be increased by 50% (gradually)

If you go from m/r to dispersible, reduce the dose by 30%

77
Q

What patient/career advice is given for levodopa combinations?

A

Take on an empty stomach
If you get GI side effects, taken it with a low protein snack or liquid (not orange juice, can have orange squash)

Urine discolouration to red/brown

Side effects

78
Q

How do patients switch between levodopa/ dopa-decarboxylase inhibitor preparations?

A

Stop the original one

Restart the new one at least 12 hours later

79
Q

How often should a rotigotine patch be changed?

A

Every 24 hours

80
Q

When using rotigotine patches, when a patch is removed how long should you avoid using a patch on that area of skin for?

81
Q

What important safety information is associated with brompcriptine?

A

Avoid abrupt withdrawal- can cause NMS
Impulse control disorders
Fibrotic reactions - symptoms include dyspnoea, cough, chest pain
Avoid if there is a history of severe cardiovascular or mental health diseases (risk of MI, seizures, hypertension, and mental disorders)

82
Q

Which classes of antiparkinsonian drugs can cause urine discolouration?

A

Levodopa

COMT inhibitors

83
Q

When should entacapone be taken if being used as an adjuvant to levodopa?

A

At bedtime

1 hour before or after levodopa is

84
Q

When should tolcapone be taken if being used as an adjuvant to levodopa?

A

At bedtime

At the same time as levodopa

85
Q

If adding a COMT inhibitor to levodopa therapy, does the dose of levodopa need to be altered?

A

Usually needs to be decreased

Because COMT inhibitors increase the half life of levodopa

86
Q

When using a selegiline oral lysophilliate, how long should patients eat, drink or wash their mouth for?

Pharmacy Pre-Reg 2020/2021 (18 decks)

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