Movement disorders

Question 1

How often should patients with Parkinson’s be reviewed?

Answer 1

Every 6-12 months

Question 2

Domperidone MHRA

Answer 2

Not indicated for those under 12 years or under 35kg

Question 3

1st line for Parkinsons patients whose motor symptoms affect their quality of life

Answer 3

Levodopa + Carbidopa/Benserazide

Question 4

Parkinsons patients whose motor symptoms do not affect their quality of life

Answer 4

Can be given levodopa, non-ergot-derived dopamine-receptor agonists (e.g. pramipexole, ropinirole, rotigotine) or monoamine-oxidase B inhibitors (e.g. rasagiline or selegiline)

Question 5

Dopamine receptor agonists

Answer 5

Non-ergot-derived: pramipexole, ropinirole, rotigotine

Question 6

Complications with levodopa treatment

Answer 6

Motor complications- response fluctuations and dyskinesia

Question 7

What are response fluctuations in Parkinsons?

Answer 7

Large variations in motor performance- normal function during ‘on’ period and weakness and restricted mobility during the ‘off’ period.

Question 8

Levodopa vs dopamine receptor agonists

Answer 8

Levodopa gives more noticeable motor improvements but more likely to experience motor compliacations
Dopamine receptor agonists are more likely to cause excessive sleepiness, hallucinations and impulse control disorders.

Question 9

If patients develop dyskinesia or motor fluctuations despite optimal levodopa therapy, what can be given?

Answer 9

A choice of:
non-ergotic dopamine-receptor agonists e.g. pramipexole, ropinirole, rotigotine
monoamine oxidase B inhibitors e.g. rasagiline or selegiline
COMT inhibitors e.g. entacapone or tolcapone

as an adjunct to levodopa

then consider ergot-derived dopamine-receptor agonists or amantidine

Question 10

Ergot-derived dopamine-receptor agonists

Answer 10

Bromocriptine
Cabergoline
Pergolide

Should only be considered as an adjunct to levodopa if the symptoms aren’t controlled by a non-ergot derived dopamine receptor agonist

Question 11

Daytime sleepiness with Parkinsons

Answer 11

Modafinil- review every 12 months

Should be advised not to drive and inform DVLA

Question 12

Nocturnal akinesia with Parkinsons

Answer 12

Levodopa or oral dopamine receptor agonists as first line and rotigotine as second line (if both first line options are ineffective)

Question 13

Postural hypotension in Parkinsons

Answer 13

First line- midodrine

Alternative- fludrocortisone (unlicensed)

Question 14

Hallucinations and delusions in Parkinsons

Answer 14

No cognitive impairments- quetiapine

If standard treatment ineffective, clozapine can be given

Question 15

Which antipsychotics can worsen the motor features of Parkinson’s disease?

Answer 15

Phenothiazines (e.g. chlorpromazine)

Butyrophenones

Question 16

Rapid eye movement sleep behaviour disorder

Answer 16

Clonazepam or melatonin

Question 17

Parkinson’s disease dementia

Answer 17

AChE inhibitor- all unlicensed except rivastigmine capsules and liquid for mild-to-moderate dementia for those with Parkinsons
Can consider memantine

Question 18

Treating advanced Parkinsons disease

Answer 18

Apomorphine hydrochloride as intermittent injections of continuous subcutaneous infusions.
Advised to administer domperidone (starting 2 days before apomorphine and discontinue as soon as possible) to control N&V associated with apomorphine.
Apomorphine + domperidone may cause QT prolongation- recommend cardiac risk assessment and ECG monitoring

Question 19

Switching between levodopa/dopa-decarboxylase inhibitor preparations

Answer 19

Should discontinue 12 hours before

Question 20

Switching from modified release levodopa to dispersible co-careldopa

Answer 20

Reduce dose by approx 30%

Question 21

Amantadine cautions

Answer 21

Confused or hallucinatory states
Congestive heart disease (may exacerbate oedema)
Elderly
Tolerance may develop in Parkinsons

Question 22

Apomorphine cautions

Answer 22

CV disease
History of postural hypotension
Neuropsychiatric disorders
Pulmonary disease
Susceptibility to QT prolongation

Question 23

Stopping anti-Parkinson meds abruptly

Answer 23

Carries small risk of neuroleptic malignant syndrome

Question 24

Monitoring for apomorphine

Answer 24

Hepatic
Haemopoietic
Renal
CV function
Test initially and every 6 months for haemolytic anaemia and thrombocytopenia if taking concomitant levodopa

Question 25

Bromocriptine

Answer 25

Pulmonary, retroperitoneal and pericardial fibrotic reactions
Exclude cardiac valvulopathy with echocardiography before starting treatment with these ergot derivatives for Parkinson’s disease or chronic endocrine disorders
Monitor for dyspnoea, persistent cough, chest pain, cardiac failure and abdominal pain or tenderness