Parkinson In class Dr. Thomason Flashcards
Classic symptoms of Parkinson’s disease
Tremor
Rigidity
Bradykenisia
Postural instability
Associated symptoms of Parkinson’s
they come along with Parkinson’s
reduced facial expression
cognitive issues
soft voice
constipation (sometimes BPH)
What are the side effects of dopamine agonists?
-Tachycardia
-BP goes down -> orthostatic hypotension
-dizziness
-the feeling of fainting
-impulsive control (especially young males -> betting, shopping) -> bipolar disorder, history of addiction)
-sleep attacks!
hallucinations at higher doses
-> often seen when titrating up
Which dopamine agonists are preferred?
Ropinirole
0.25 mg TID -> titrate up every week
Pramipexole
0.125 mg TID -> Titrate up every week
Other counseling points - Dopamine agonists
take with food - to reduce nausea
can cause Raynauds-like symptoms white hands
What are treatment options in patients who started on Dopamine agonists, but still have symptoms?
Max out the dose of dopamine agonists (as high as they can tolerate without side effects)
-consider levodopa even if younger than 65
-consider adding MAO-B
What is the role of MAO inhibitors?
Adjunctive to Dopamine agonist
-Selegeineis metabolized to an amphetamine
-> take it in the morning and with lunch (BID) so that patients won’t be awake all night
Which MAO-inhibitor is converted to an amphetamine?
Selegiline is metabolized to an amphetamine
-> take it in the morning and with lunch (BID) so that patients won’t be awake all night
When to be cautious when using MAO inhibitors?
Serotonin syndrome at higher doses and when using serotonergic agents:
St. Johns Wort
Tramadol
Cyclobenzaprine (skeletal muscle relexant)
Triptans
antidepressants
Side effects of MAO-inhibitors
increases levodopa ADE
-agitation
-maniac
-insomnia
-confusion
-sweating, shivering
-hypertension
Which class of drugs may be helpful for treating tremors?
Anticholinergics: dont use it at the age over 65
Benztropine (Cogentin)
Trihexyphenidyl
-can be used as monotherapy
-or added to levodopa
ADE of Anticholinergics
-dry eyes, increased risk of glaucoma
-dry mouth
-constipation
-less ability to sweat
-delirium in elderly
Role of Amantadine
adjunctive to levodopa to treat dyskenisia in PD
but also helps with tremors and rigidity
-patients may become tolerant
-renal dose adjustment
What is an unsual side effect specifically of Amantadine?
livedo reticularis
How should l-dopa be given?
Sinemet (coformulation with carbadopa)
-immediate release
How many mg of carbadopa is required for sufficient l-dopa to get to the brain?
75 mg carbadopa
thats we start with 25/100 TID
-> 25*3 = 75 mg of carbadopa
What might interfere with levodopa absorption?
High-protein diet
At what dose of levodopa do we rule out PD?
1000 mg
ADE of levodopa
-postural hypotension
-hallucinations
-dyskenisia
-akathisia (cant remain still)
Characteristis of levo dopa induced ADE
Motor fluctuations: fe: can’t move in the morning Wearing off –> effectiveness is not as long anymore
periods of no movement followed by periods of fluid like state with dyskenitc activity: ON-OFF
dyskinesia: related to peaks of levodopa
becomes frozen when he has to cross the threshold of an elevator or when they need to move quickly
What might help with Wearing OFF symptoms
-giving smaller and more frequent doses of levodopa
-adding a COMT-inhibitor
-or adding a MOA-B inhibitor
-surgery (brain stimulation)
What is the role of COMT-inhibitors in PD therapy?
-adjunctive to levodopa (reduce to by about a quarter)
-it the halflife of levodopa in wearing off phase (during wearing off levodopa’s effectiveness doesn’t last as long)
What is an important counseling point for Entacapone?
Discoloration of urine (brown)
Which drug should be given before administering apomorphine?
trimethobenzamide (antiemetic) -> start 3 days before apomorphine -> for 2 months
when given with another antiemetic it can cause hypotension
because apomorphine (dopamine agonist) causes severe N/V
-apomorphine requires renal dose adjustment
