Drug management of motor symptoms in Parkinson's disease

Question 1

Parkinson’s disease is a progressive neurodegenerative condition resulting from the death of which cells in the brain?

Answer 1

Dopaminergic cells of the substantia nigra

Question 2

Patients with parkinson’s disease classically present with motor-symptoms. List the most common symptoms (5)

Answer 2

1) Hypokinesia
2) Bradykinesia
3) Rigidity
4) Rest tremor
5) Postural instability

Question 3

list the Non-motor symptoms associated with parkinsons disease (7)

Answer 3

1) Dementia
2) Depression
3) Sleep disturbances
4) Bladder and bowel dysfunction
5) Speech and language changes
6) Swallowing problems
7) Weight loss

Question 4

1) How often should a person with parkinsons be reviewed by their specialist?
2) When Parkinson’s disease diagnosis is confirmed who should the patient inform?

Answer 4

1) Every 6 to 12 month

2) DVLA and their car insurer

Question 5

Outline the non-drug treatment options for the management of parkinsons disease (4)

Answer 5

1) Physiotherapy for balance or motor function problems
2) SALT for communication, swallowing or saliva problems
3) Occupational therapy - difficulties with daily activities
4) Possibly dietitian

Question 6

What is the first line treatment in the early stages of Parkinson’s disease, for patients whose motor symptoms decrease their QOL?

Answer 6

levodopa combined with carbidopa (co-careldopa) or benserazide (co-beneldopa)

Question 7

Parkinson’s disease patients whose motor symptoms do not affect their QOL can be prescribed which pharmacological options?

Answer 7

1) A choice of levodopa, non-ergot-derived dopamine-receptor agonists: Pramipexole, ropinirole or rotigotine
2) Or Monoamine-oxidase-B inhibitors: Rasagiline or Selegiline

Question 8

Patients should be informed about the risk of adverse reactions from antiparkinsonian drugs. Summarise some of the common adverse effects caused by these drugs (3)

Answer 8

1) Psychotic symptoms
2) Excessive sleepiness and sudden onset of sleep with dopamine-receptor agonists
3) Impulse control disorders with all dopaminergic therapy (especially dopamine-receptor agonists)

Question 9

Summarise some of the complications associated with levedopa treatment

Answer 9

1) Motor complications, including response fluctuations and dyskinesias
2) Response fluctuations- essentially large variations in motor performance. So normal function during ‘on’ period, and restricted mobility during the ‘off’ period
3) End-of-dose- deterioration can also occur

Question 10

End-of-dose deterioration is a complication associated with levedopa treatment. Explain what this is and how should it be managed?

Answer 10

1) Progressively shorter duration of benefit occurs from treatment
2) M/R preparations may help with ‘end-of-dose’ deterioration or nocturnal immobility

Question 11

For each of the following, state if the answer is levedopa or dopamine-receptor agonists:

1) Overall improvement in motor performance is more noticeable with which drug?
2) Motor complications are less likely to occur with which drug when used alone long-term?
3) excessive sleepiness, hallucinations, and impulse control disorders are more likely to occur with which drug?

Answer 11

1) overall improvement in motor performance is more noticeable with levodopa
2) Motor complications are less likely to occur with dopamine-receptor agonists
3) Excessive sleepiness, hallucinations, and impulse control disorders are more likely to occur with dopamine-receptor agonists

Question 12

Explain why antiparkinsonian drug concentrations should not be allowed to fall suddenly e.g. due to poor absorption or abrupt withdrawal?

Answer 12

To avoid the potential for acute akinesia or neuroleptic malignant syndrome

Question 13

Patients who develop dyskinesia or motor fluctuations despite optimal levodopa therapy should be offered which drugs as an adjunct to levodopa? (3)

Answer 13

Choice of one of the following:

1) Non-ergotic dopamine-receptor agonists E.g. Pramipexole, ropinirole, rotigotine
2) Or monoamine oxidase B inhibitors e.g. rasagiline or selegiline
3) Or a COMT inhibitor e.g. entacapone or tolcapone

Question 14

when should a ergot-derived dopamine-receptor agonist e.g. bromocriptine, cabergoline or pergolide be considered in the management of parkinsons?

Answer 14

An adjunct to levodopa if symptoms are not adequately controlled with a non-ergot-derived dopamine-receptor agonist

Question 15

when would amantadine be considered in parkinsons?

Answer 15

If dyskinesia is not adequately managed by modifying existing therapy