NS: Parkinson's disease

Question 1

Parkinson’s disease is a progressive neurodegenerative condition resulting from what?

Answer 1

The death of dopaminergic cells in the substantia nigra in the brain.

Question 2

Patients with Parkinson’s disease classically present with motor-symptoms including what?

Answer 2

Patients with Parkinson’s disease classically present with motor-symptoms including hypokinesia, bradykinesia, rigidity, rest tremor, and postural instability.

Question 3

Non-motor symptoms of parkinson’s disease include what?

Answer 3

Dementia
Sleep issues.
Depression
Bladder
Bowel dysfunction
Speech and language changes. 
Swallowing problems
Weight loss

Question 4

Patients with suspected Parkinson’s disease should be referred to a specialist and reviewed at what frequency?

Answer 4

Patients with suspected Parkinson’s disease should be referred to a specialist and reviewed every 6 to 12 months. When Parkinson’s disease diagnosis is confirmed, patients should be advised to inform the DVLA and their car insurer.

Question 5

Patients with suspected Parkinson’s disease should be referred to a specialist and reviewed every 6 to 12 months. When Parkinson’s disease diagnosis is confirmed, patients should be advised to inform who?

Answer 5

Patients with suspected Parkinson’s disease should be referred to a specialist and reviewed every 6 to 12 months. When Parkinson’s disease diagnosis is confirmed, patients should be advised to inform the DVLA and their car insurer.

Question 6

In early stages of Parkinson’s disease, patients whose motor symptoms decrease their quality of life should be offered what?

Answer 6

Levodopa combined with carbidopa (co-careldopa) or benserazide (co-beneldopa).

Carbidopa inhibits peripheral metabolism of levodopa, allowing a greater proportion of peripheral levodopa to cross the blood-brain barrier for central nervous effect.

Benserazide is a peripherally-acting aromatic L-amino acid decarboxylase (DOPA decarboxylase inhibitor) which has the same effect.

Question 7

Parkinson’s disease patients whose motor symptoms do NOT affect their quality of life could be prescribed a choice of what drugs? (3)

Answer 7

1. Levodopa
2. Non-ergot derived dopamine-receptor agonists (pramipexole, ropinirole, rotigotine).
3. Monoamine-oxidase-B inhibitors (rasagiline or selegiline)

Question 8

All dopaminergic therapy, but especially dopamine-receptor agonists, can cause what?

Answer 8

Impulse control disorders

Question 9

Pramipexole is what type of drug?

Answer 9

Parkinson’s disease patients whose motor symptoms do not affect their quality of life, could be prescribed a choice of levodopa, non-ergot-derived dopamine-receptor agonists (pramipexole, ropinirole or rotigotine) or monoamine-oxidase-B inhibitors (rasagiline or selegiline hydrochloride).

Question 10

Adverse reactions from antiparkinsonian drugs can include what?

Answer 10

1. Psychotic symptoms
2. Excessive sleepiness and sudden onset of sleep.
3. impulse control disorders

Question 11

Rasagiline is what type of drug?

Answer 11

Parkinson’s disease patients whose motor symptoms do not affect their quality of life, could be prescribed a choice of levodopa, non-ergot-derived dopamine-receptor agonists (pramipexole, ropinirole or rotigotine) or monoamine-oxidase-B inhibitors (rasagiline or selegiline hydrochloride).

Question 12

Levodopa treatment is associated with motor complications, including response fluctuations and dyskinesias. Response flucations are characterised by what?

Answer 12

Levodopa treatment is associated with motor complications, including response fluctuations and dyskinesias. Response fluctuations are characterised by large variations in motor performance, with normal function during the ‘on’ period, and weakness and restricted mobility during the ‘off’ period. ‘End-of-dose’ deterioration with progressively shorter duration of benefit can also occur. Modified-release preparations may help with ‘end-of-dose’ deterioration or nocturnal immobility.

Question 13

‘End-of-dose’ deterioration can be an issue with levodopa treatment, how can it me managed?

Answer 13

Levodopa treatment is associated with motor complications, including response fluctuations and dyskinesias. Response fluctuations are characterised by large variations in motor performance, with normal function during the ‘on’ period, and weakness and restricted mobility during the ‘off’ period. ‘End-of-dose’ deterioration with progressively shorter duration of benefit can also occur. Modified-release preparations may help with ‘end-of-dose’ deterioration or nocturnal immobility.

Question 14

Selegiline is what type of drug?

Answer 14

Parkinson’s disease patients whose motor symptoms do not affect their quality of life, could be prescribed a choice of levodopa, non-ergot-derived dopamine-receptor agonists (pramipexole, ropinirole or rotigotine) or monoamine-oxidase-B inhibitors (rasagiline or selegiline hydrochloride).

Question 15

Overall improvement in motor performance is more noticable with what antiparkinson’s treatment?

Answer 15

The overall improvement in motor performance is more noticeable with levodopa than with dopamine-receptor agonists, and motor complications are less likely to occur with dopamine-receptor agonists when used alone long-term. Conversely, excessive sleepiness, hallucinations, and impulse control disorders are more likely to occur with dopamine-receptor agonists than with levodopa.

Question 16

Excessive sleepiness, hallucinations, and impulse control disorders are more likely to occur with what drugs?

Answer 16

The overall improvement in motor performance is more noticeable with levodopa than with dopamine-receptor agonists, and motor complications are less likely to occur with dopamine-receptor agonists when used alone long-term. Conversely, excessive sleepiness, hallucinations, and impulse control disorders are more likely to occur with dopamine-receptor agonists than with levodopa.

Question 17

Ropinirole is what type of drug?

Answer 17

Parkinson’s disease patients whose motor symptoms do not affect their quality of life, could be prescribed a choice of levodopa, non-ergot-derived dopamine-receptor agonists (pramipexole, ropinirole or rotigotine) or monoamine-oxidase-B inhibitors (rasagiline or selegiline hydrochloride).

Question 18

Patients who develop dyskinesia or motor fluctuations despite optimal levodopa therapy should be offered a choice of what as an adjunctive treatment to levodopa? (3)

Answer 18

Patients who develop dyskinesia or motor fluctuations despite optimal levodopa therapy should be offered a choice of non-ergotic dopamine-receptor agonists (pramipexole, ropinirole, rotigotine), monoamine oxidase B inhibitors (rasagiline or selegiline hydrochloride) or COMT inhibitors (entacapone or tolcapone) as an adjunct to levodopa.

Question 19

What type of drug is entacapone?

Answer 19

COMT inhibitor

Question 20

An ergot-derived dopamine-receptor agonist (bromocriptine, cabergoline or pergolide) should only be considered as an adjunct to levodopa when?

Answer 20

An ergot-derived dopamine-receptor agonist (bromocriptine, cabergoline or pergolide) should only be considered as an adjunct to levodopa if symptoms are not adequately controlled with a non-ergot-derived dopamine-receptor agonist.

Question 21

Rotigotine is what type of drug?

Answer 21

Parkinson’s disease patients whose motor symptoms do not affect their quality of life, could be prescribed a choice of levodopa, non-ergot-derived dopamine-receptor agonists (pramipexole, ropinirole or rotigotine) or monoamine-oxidase-B inhibitors (rasagiline or selegiline hydrochloride).

Question 22

What type of drug is tolcapone?

Answer 22

COMT inhibitor

Question 23

If dyskinesia is not adequately managed by modifying existing antiparkinson’s therapy, what NMDA receptor antagonist should be considered?

Answer 23

Amantadine

Question 24

Patients who experience daytime sleepiness or sudden onset of sleep, should have their Parkinson’s drug treatment adjusted under specialist medical guidance.

If reversible pharmacological and physical causes have been excluded, what drug treatment can be considered?

Answer 24

Patients who experience daytime sleepiness or sudden onset of sleep, should have their Parkinson’s drug treatment adjusted under specialist medical guidance. If reversible pharmacological and physical causes have been excluded, MODAFINIL should be considered to treat excessive daytime sleepiness, and treatment should be reviewed at least every 12 months.

Question 25

When treating nocturnal akinesia (loss of voluntary movement/function) in patients with Parkinson’s disease, what should be considered as first-line options?

Answer 25

When treating nocturnal akinesia in patients with Parkinson’s disease, levodopa or oral dopamine-receptor agonists should be considered as first-line options and rotigotine as second-line (if both levodopa or oral dopamine-receptor agonists are ineffective).

Question 26

When treating nocturnal akinesia (loss of voluntary movement/function) in patients with Parkinson’s disease, what should be considered as the second line option if both levodopa or oral dopamine-receptor agonists are ineffective?

Answer 26

When treating nocturnal akinesia in patients with Parkinson’s disease, levodopa or oral dopamine-receptor agonists should be considered as first-line options and rotigotine as second-line (if both levodopa or oral dopamine-receptor agonists are ineffective).

Question 27

Patients with Parkinson’s disease who develop postural hypotension should have their drug treatment reviewed to address any pharmacological cause. If drug therapy is required, what is the first line option?

Answer 27

Midodrine hydrochloride, fludrocortisone acetate (unlicensed) is an alternative.

Question 28

Patients with Parkinson’s disease who develop postural hypotension should have their drug treatment reviewed to address any pharmacological cause. If drug therapy is required what is the second option if midodrine does not work?

Answer 28

Patients with Parkinson’s disease who develop postural hypotension should have their drug treatment reviewed to address any pharmacological cause. If drug therapy is required, midodrine hydrochloride should be considered as the first option and fludrocortisone acetate [unlicensed indication] as an alternative.

Question 29

What drugs are firstline for depression in PD?

Answer 29

SSRIs but caution the impact on blood pressure.

Question 30

In PD with no cognitive impairment, what medication can be considered to treat hallucinations and delusions?

Answer 30

quetiapine [unlicensed indication]

Question 31

What is the place of modafinil in Parkinsons treatment?

Answer 31

Patients who experience daytime sleepiness or sudden onset of sleep, should have their Parkinson’s drug treatment adjusted under specialist medical guidance. If reversible pharmacological and physical causes have been excluded, modafinil should be considered to treat excessive daytime sleepiness, and treatment should be reviewed at least every 12 months.

Question 32

If standard treatment is not effective in reducing hallucinations and delusions in PD, what drug should be offered?

Answer 32

Clozapine if quetiapine has not worked.

Question 33

If a pharmalogical cause for rapid eye movement sleep behaviour disorder in PD patients has been ruled out, what drugs should be tried?

Answer 33

Clonazepam or melatonin both unlicensed.

Question 34

What three drugs could be used to treat drooling of saliva in PDs?

Answer 34

1. Glycopyrronium bromide [unlicensed] first-line.
2. Botulinum toxin type A [unlicensed] second line.
3. Atropine topical if risk of cognitive adverse effects is thought to be minimal.

Question 35

What drug can be offered to patients with advanced Parkinson’s disease as intermittent injections or continuous subcutaneous infusions?

Answer 35

Apomorphine, to control the nausea and vomiting associated with apopmorphine, domperidone is usually started two days before apomorphine therapy and then discontinued as soon as possible.

Question 36

Why is domperidone started two days before treatment with apopmorphine?

Answer 36

Patients with advanced Parkinson’s disease can be offered apomorphine hydrochloride as intermittent injections or continuous subcutaneous infusions. To control nausea and vomiting associated with apomorphine, administration of domperidone is usually started two days before apomorphine therapy, and then discontinued as soon as possible.

Question 37

What is the risk of combined domperidone and apomorphine therapy?

Answer 37

To reduce the risk of serious arrhythmia due to QT prolongation associated to the concomitant use of domperidone and apomorphine hydrochloride, the MHRA recommends an assessment of cardiac risk factors and ECG monitoring and to ensure that the benefits outweighs the risks when initiating treatment.

Question 38

When managing impulse control disorders, dopamine-receptor agonists may need to be stopped. How should this be done in practice?

Answer 38

When managing impulse control disorders, dopamine-receptor agonist doses should be reduced gradually and patients should be monitored for symptoms of dopamine agonist withdrawal. Specialist cognitive behavioural therapy should be offered if modifying dopaminergic therapy is not effective.

Question 39

What else can ropinirole be used for other than Parkinson’s disease?

Answer 39

Restless legs syndrome,
Dose adjuctment might be needed if smoking is started or stopped during treatment.

Ropinirole may suppress lactation, cause hypotension and sudden onset of sleep.

Question 40

What parkinsons drug may require dose adjustment if smoking is started or stopped during therapy?

Answer 40

Restless legs syndrome,
Dose adjuctment might be needed if smoking is started or stopped during treatment.

Ropinirole may suppress lactation, cause hypotension and sudden onset of sleep.

Question 41

What are the side effects of ropinirole?

Answer 41

Restless legs syndrome,
Dose adjuctment might be needed if smoking is started or stopped during treatment.

Ropinirole may suppress lactation, cause hypotension and sudden onset of sleep.

Question 42

Dopamine receptor agonists predominantly target what receptor for clinical effect?

Answer 42

D2 but have effects at the other receptor subtypes

Question 43

Pramipexole and ropinirole work at what dopamine receptors?

Answer 43

D2 and D3.

D3 is responsbile for dopamine dysregulation syndrome like sexual dysfunction and gambling.

Question 44

Tolcapone and entacapone are what drug class?

Answer 44

COMT inhibitors.
Prevent breakdown of levodopa in both the CNS and periphery.

Tolcapone crosses the BBB, Entacapone does not.

Half life of both ~2hrs.

Question 45

Which of the following does and which of the following does not cross the BBB?

Tolcapone
Entacapone

Answer 45

COMT inhibitors.
Prevent breakdown of levodopa in both the CNS and periphery.

Tolcapone crosses the BBB, Entacapone does not.

Half life of both ~2hrs.

Question 46

Of the following agents, motor complications are more likely to occur with what?

Levodopa
Dopamine agonists
MAO-B inhibitors

Answer 46

Motor complications are more common with levodopa.

Adverse events are more common with dopamine receptor agonists.

Question 47

Levodopa-carbidopa can colour the urine

Answer 47

Red-brown

Question 48

Why is the role of amantadine in therapy limited?

Answer 48

Tolerance rapidly develops.