Chapter 69: Parkinson's Disease

Question 1

Parkinson’s Disease occurs when

Answer 1

neurons in the substantia nigra die or become impaired

Question 2

The cells in the substantia nigra produce which NT?

Answer 2

Dopamine - which allows smooth, coordinated function of body muscles and movement

Question 3

What are the TRAP major symptoms of PD (due to less dopamine)

Answer 3

Tremor - when resting
Rigidity - in legs, arms, trunk and face (mask-like face)
Akinesia/bradykinesia - lack of/slow start in movement
Postural instability - imbalance, falls

Question 4

What can be used to measure involuntary movements (i.e., tardive dyskinesias) from medications

Answer 4

The Abnormal Involuntary Movement Scale (AIMS)

Question 5

Which drugs can worsen PD

Answer 5

Any drugs that block DA such as:

• Phenothiazines (e.g., prochlorperazine) used for psychosis, nausea, agitation
• Butyrophenones (e.g., haloperidol, droperidol) used for psychosis and behavior disorders or nausea
• FGA and SGA (e.g., risperidone at higher doses, paliperidone); lowest risk with quetiapine
• Metoclopramine, a renally-cleared drug that can accumulate in elderly patients

Question 6

Even with high doses of PD drugs and various combinations, the disease will progress, including extended periods of “off time.” What does this mean

Answer 6

When symptoms of the disease worsen before the next dose of medication is due

Question 7

Patients with PD have a high incidence of ___

Answer 7

depression. SSRIs or SNRIs are commonly used for treatment

Question 8

Besides SSRIs and SNRIs, what other treatments can be used for depression in PD

Answer 8

TCAs (preferably secondary amines like desipramine and nortiptyline) and the DA agonist pramipexole

Question 9

What is the preferred antipsychotic drug for PD psychosis & why

Answer 9

Quetiapine; low risk of movement disorders, but it can cause metabolic complications, including increased cholesterol and BG

Question 10

pimavanserin is indicated for what?

Answer 10

a 5HT2A/2C receptor inverse agonist
to treat hallucinations and delusions in PD

Question 11

T/F: levodopa and dopamine agonist do NOT need to be tapered

Answer 11

false
must taper - risk of life-threatening condition similar to NMS

Question 12

What is the most effective treatment for PD

Answer 12

Levodopa (a prodrug of DA)

Question 13

What medication is given with Levodopa & what is the combination called (brand name)

Answer 13

Carbidopa
Sinemet

Question 14

Why is carbidopa given with levodopa

Answer 14

To prevent the peripheral metabolism of levodopa, which would destroy much of the drug before it crosses the BBB

Question 15

Which drug class is used commonly for initial treatment in younger patients and eventually used in most patients with PD

Answer 15

DA agonists

Question 16

Tremor-predominant disease in younger patients can be treated with a ______

Answer 16

Centrally-acting anticholinergic

beers criteria for elderly individuals

Question 17

Which drug is a precursor of dopamine

Answer 17

levodopa

Question 18

sinemet generic name

Answer 18

carbidopa/levodopa

Question 19

What is the MOA of carbidopa

Answer 19

Inhibits dopa decarboxylate enzyme, preventing peripheral metabolism of levodopa

Question 20

What is the starting dose for Sinemet IR

Answer 20

25/100 mg PO TID

Question 21

T/F: Sinemet ER tablet CAN be cut in half

Answer 21

True

Question 22

T/F: Rytary (carbidopa/levodopa ER capsule) can be sprinkled on a small amount of applesauce

Answer 22

True

Question 23

What is a CI for Sinemet

Answer 23

Non-selective MAO inhibitors within 14 days, narrow angle glaucoma

Question 24

Side effects of Sinemet

Answer 24

Nausea, dizziness, orthostasis, dyskinesias, hallucinations, psychosis

Can cause brown, black, or dark discoloring of urine, saliva or sweat and can discolor clothing; positive Coombs test: discontinue drug (hemolysis risk); unusual sexual urges, priapism

Question 25

How many mg/day of carbidopa is required to inhibit dopa decarboxylate

Answer 25

70-100

Question 26

Long-term use of Sinemet can lead to

Answer 26

fluctuations in response and dyskinesias

Question 27

MOA of COMT inhibitors

Answer 27

increase the duration of action of levodopa; inhibit the enzyme COMT to prevent peripheral conversion of levodopa

Question 28

Which drug is a COMT inhibitor

Answer 28

Entacapone, opicapone, tolcapone

Question 29

COMT inhibitors should only be used with ____

Answer 29

levodopa

Question 30

Dosing for entacapone

Answer 30

200 mg PO with each dose of carbidopa/levodopa

Question 31

Dopamine agonist MOA

Answer 31

act similar to DA at the DA receptor

Question 32

Which medications are dopamine agonists

Answer 32

Pramipexole, Ropinerole, Rotigotine

Question 33

Generic name for Mirapex, Mirapex ER

Answer 33

pramipexole

Question 34

Brand name for ropinerole

Answer 34

Requip

Question 35

Generic name for Neupro

Answer 35

rotigotine

Question 36

Dopamine agonist warnings

Answer 36

Somnolence (including sudden daytime sleep attacks), orthostasis, hallucinations, dyskinesias

Question 37

Which Dopamine Agonist comes as a patch

Answer 37

Rotigotine (Neupro)

Question 38

How should Neupro be used

Answer 38

Apply **once daily** at the same time each day to the stomach, thigh, hip, side of body, shoulder or upper arm; do not use the same site for at least 14 days

Question 39

Rotigotine should be avoided if a patient has a sensitivity/allergy to ____

Answer 39

sulfites

Question 40

T/F: Rotigotine patch does not need to be removed before an MRI

Answer 40

False

Question 41

Which drug is a dopamine agonist injection for advanced disease (a "rescue" movement drug for "off" periods)

Answer 41

Apomorphine (Apokyn)

Question 42

Where must the first dose of apomorphine be administered in?

Answer 42

Medical office (a test dose)

Question 43

Contraindication for apomorphine

Answer 43

Do not use with 5HT3 antagonists (e.g., ondansetron) due to severe hypotension and loss of consciousness

Question 44

Side effects of apomorphine

Answer 44

Severe nausea/vomiting, hypotension

Question 45

For emesis prevention, what can be given with apomorphine 3 days prior to initial dose

Answer 45

trimethobenzamide (Tigan)

Question 46

MOA of amantadine

Answer 46

**blocks DA reuptake** into presynaptic neurons and increases DA release from presynaptic fibers. Primarily used to treat dyskinesias associated with peak-dose of Sinemet

Question 47

Amantadine warnings

Answer 47

Somnolence, psychosis

Question 48

Amantadine side effects

Answer 48

dizziness, orthostatic hypotension, livedo reticularis (reddish skin mottling - can require drug d/c)

Question 49

Which medications are selective MAO-B inhibitors used in PD

Answer 49

Selegiline, rasagiline, safinamide

Question 50

Which MAO-B should not be taken at bedtime due to activating effects

Answer 50

Selegiline

Question 51

MOA of MAO-B inhibitors

Answer 51

block the breakdown of DA which increases dopaminergic activity

Question 52

CI of MAO-B inhibitors

Answer 52

Use in combination with other MAOi (including linezolid), opioids, SNRIs, TCAs

Question 53

Warnings of MAO-B inhibitors

Answer 53

Serotonin syndrome, hypertension

Question 54

Which centrally acting anticholinergic medications are used in PD

Answer 54

Benztropine and trihexyphenidyl

Question 55

Cogentin generic name

Answer 55

benztropine

Question 56

Side effects of benztropine

Answer 56

anticholinergic SEs: dry mouth, constipation, urinary retention, blurred vision, somnolence, confusion

Question 57

Droxidopa is used for neurogenic orthostatic hypotension. What are the side effects

Answer 57

Syncope, falls, HA

Question 58

MOA-B inhibitors should not be used with foods high in tryamine such as

Answer 58

aged or mature cheese, air-dried or cured meats, including sausages and salamis, saurkraut, fava or broad bean pods, tap/draft beers, soy sauce

Question 59

rasagiline is ____ substrate what should be done with inhibitor?

Answer 59

CYP1A2 limit dose to 0.5mg with cipro (or other 1A2 inhibitors)