dopamine receptor agonists - PD

Question 1

name the 4 non ergot derived DRA

Answer 1

pramipexole
rotigotine
ropinirole
apomorphine

Question 2

3 out of 4 non-ergot derived DRAs can be used for restless legs. which ones

Answer 2

pramipexole
rotigotine
ropinirole

Question 3

dopamine receptor agonists are associated with impulse control disorders e.g. pathological gambling, binge eating, hyper sexuality. will switching between different DRA (i.e. ergot and non ergot) control these SE?

Answer 3

No, ergot and non-ergot derived DRA do not differ in their likelihood to cause impulse control disorders

Question 4

amantadine - drug action

Answer 4

weak dopamine agonist with modest antiparkinsonian effects

Question 5

when is amantadine indicated in PD

Answer 5

if pt develops dyskinesia and it is not adequately managed by modifying existing therapy, consider amantadine

Question 6

amantadine - 2 contraindications

Answer 6

epilepsy
Hx gastric ulcer

Question 7

this drug is used for PD, and is also licensed for prophylaxis and treatment of influenza A (but not recommended)

Answer 7

amantadine

Question 8

when is apomorphine indicated in PD

Answer 8

severe PD - refractory motor fluctuations in PD (‘off’ episodes) that are inadequately controlled by co-beneldepa or co-careldopa or other dopaminergic, under expert supervision

Question 9

Apomorphine is given with this antiemetic to reduce risk of nausea and vomiting, however there is an interaction between them both

Answer 9

domperidone
both increase risk of QT interval prolongation so it is advised they are actually avoided

Question 10

name the 3 ergot derived DRA

Answer 10

• bromocriptine
• cabergoline
• quinagolide

Question 11

drug action of bromocriptine

Answer 11

stimulant of dopamine receptors in brain
also inhibits release of prolactin by pituitary

Question 12

which 2 ergot derived DRA are licensed for suppression of lactation (although not recommended for routine suppression, or for the relief of symptoms of PP pain and engorgement) that can be adequately treated with simple analgesics and breast support

Answer 12

bromocriptine
cabergoline (preferred)

Question 13

important safety info bromocriptine - fibrotic and serosal reactions

Answer 13

• esp with long term and high dose treatment
• associated with pulmonary, pleural, retroperitoneal and pericardial fibrosis (latter often manifests as cardiac failure), pleural and pericardial effusions, and constrictive pericarditis
• baseline investigations and regular monitoring for signs and symptoms of these reactions should be undertaken and treatment stopped if suspected

Question 14

important safety info for bromocriptine - impulse control disorders

Answer 14

DRA associated with impulse control disorders
inform pt and carer of the risk
ergot and non-ergot do not differ in their propensity to cause impulse control disorders

Question 15

bromocriptine important safety info - prevention or suppression of lactation

Answer 15

only use where medically indicated! e..g intrapartum loss, neonatal death, mother with HIV infection
do not use for routine suppression of lactation or to relieve symptoms of PP breast pain and engorgement
monitor BP carefully esp during first days of treatment

Question 16

bromocriptine is contraindicated in…

Answer 16

uncontrolled hypertension
hypertensive disorders of pregnancy (e.g. pre-eclampsia, eclampsia, pregnancy induced hypertension)
hypertension in PP women or in puerperium
cardiac valvulopathy (exclude before long term treatment)

Question 17

discontinue bromocriptine immediately if …

Answer 17

hypertension, suggestive chest pain, severe progressive or unremitting headache (sign of stroke), or signs of CNS toxicity

Question 18

what to do if GI bleeding occurs with bromocriptine

Answer 18

withdraw

Question 19

DRA - sudden onset of sleep

Answer 19

• excessive daytime sleepiness and sudden onset of sleep can occur with DRA
• warn pt of risk and the need to exercise caution when driving or operating machinery
• if excessive sedation or sudden onset of sleep, refrain from driving or operating machinery until effect stopped

Question 20

DRA - hypotensive reactions

Answer 20

• can occur in some pt taking DRA
• can be particularly problematic during first few days of treatment
• exercise care when driving or operating machinery

Question 21

bromocriptine monitoring

Answer 21

• BP few days after starting and following dose increase
• baseline chest X rays/lung function tests, serum creatinine, inflammatory markers before starting treatment
• monitor for fibrotic or serosal inflammatory changes during treatment

Question 22

bromocriptine - fibrotic or serosal inflammatory changes during treatment manifest as

Answer 22

dyspnoea, persistent cough, chest pain, cardiac failure, back pain, lower limb oedema, or renal impairment. discontinue if suspected.

Question 23

cabergoline drug action

Answer 23

stimulant of dopamine receptors in the brain and it also inhibits release of prolactin by the pituitary.

Question 24

cabergoline - fibrotic reactions, safety info

Answer 24

• risk of pulmonary, retroperitoneal, pericardial fibrotic reactions
• exclude cardiac valvulopathy with ECG before treatment for ergot derivatives for PD or chronic endocrine disorders
• may also be appropriate to measure ESR and creatinine and obtain chest X ray
  monitor pt for dyspnoea, persistent cough, chest pain, cardiac failure, abdominal pain or tenderness
• LFTs may be helpful if long term treatment needed
• regularly mounter for cardiac fibrosis by ECG (within 3-6m of initiation, subsequently at 6-12m intervals)

Question 25

This needs to be excluded before treatment with ergot derived DPA (does not apply to suppression of lactation)

Answer 25

cardiac valvulopathy

Question 26

Avoid these abx inhibitors with cabergoline, bromocriptine etc (ergot derived) because…

Answer 26

they are predicted to increase conc of these ergot derivatives.

e.g. clarithormycin, erythromycin

Question 27

monitoring requirements for cabergoline

Answer 27

• monitor for fibrotic disease
• monitor BP few days after starting and following dose increase

Question 28

monitoring of pt parameters with pramipexole

Answer 28

risk of postural hypotension, esp on initiation
monitor BP

Question 29

dose adjustment may be necessary if smoking is started or stopped during treatment with this non ergot derived DRA

Answer 29

ropinirole

Question 30

why should you use antipsychotics in caution with non ergot derived DRA? (interaction)

Answer 30

they are predicted to decrease the effects of ropinirole
also they both increase risk of hypotension and sedation

Question 31

CHC and HRT and non-ergot derived - interaction

Answer 31

CHC are predicted to increase exposure to ropinirole
HRT decreases clearance, thus increases exposure

monitor and adjust dose

Question 32

ropinirole for PD - what to do if treatment is interrupted for one day or more

Answer 32

re-initiation by dose titration should be considered

Question 33

rotigotine - what form is available

Answer 33

transdermal patches

Question 34

max dose rotigotine when used as MONOTHERAPY in PD

Answer 34

max 8mg/24h a day

Question 35

max dose rotigotine when used as ADJUNCTIVE therapy with co-beneldopa or co-careldopa in PD

Answer 35

max 16mg/24h per day

Question 36

max dose rotigotine when used for moderate to severe restless legs syndrome

Answer 36

max 3mg/24h per day

Question 37

cautions with rotigotine

Answer 37

avoid exposure of patch to heat
remove patch before MRI or cardioversion (aluminium containing)

Question 38

a patient is on rotigotine patch for PD. she has an upcoming MRI. will she need to remove it.

Answer 38

yes because aluminium containing

Question 39

monitoring requirements for rotigotine

Answer 39

ophthalmic testing recommend

Question 40

rotigotine - directions for administration

Answer 40

apply patch to clean, dry, intact, healthy and non-irritated skin on torso, thigh, hip, shoulder or upper arm by pressing the patch firmly against the skin for about 30 seconds
Patches should be removed after 24 hours and the replacement patch applied on a different area (avoid using the same area for 14 days)

Question 41

what areas of the body is it advised to put rotigotine patches on (5)

Answer 41

torso, thigh, hip, shoulder or upper arm