Parkinson In class Dr. Thomason

Question 1

Classic symptoms of Parkinson’s disease

Answer 1

Tremor
Rigidity
Bradykenisia
Postural instability

Question 2

Associated symptoms of Parkinson’s

Answer 2

they come along with Parkinson’s

reduced facial expression
cognitive issues
soft voice
constipation (sometimes BPH)

Question 3

What are the side effects of dopamine agonists?

Answer 3

-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

Question 4

Which dopamine agonists are preferred?

Answer 4

Ropinirole
0.25 mg TID -> titrate up every week

Pramipexole
0.125 mg TID -> Titrate up every week

Question 5

Other counseling points - Dopamine agonists

Answer 5

take with food - to reduce nausea
can cause Raynauds-like symptoms white hands

Question 6

What are treatment options in patients who started on Dopamine agonists, but still have symptoms?

Answer 6

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

Question 7

What is the role of MAO inhibitors?

Answer 7

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

Question 8

Which MAO-inhibitor is converted to an amphetamine?

Answer 8

Selegiline is metabolized to an amphetamine

-> take it in the morning and with lunch (BID) so that patients won’t be awake all night

Question 9

When to be cautious when using MAO inhibitors?

Answer 9

Serotonin syndrome at higher doses and when using serotonergic agents:

St. Johns Wort
Tramadol
Cyclobenzaprine (skeletal muscle relexant)

Triptans
antidepressants

Question 10

Side effects of MAO-inhibitors

Answer 10

increases levodopa ADE
-agitation
-maniac
-insomnia
-confusion
-sweating, shivering
-hypertension

Question 11

Which class of drugs may be helpful for treating tremors?

Answer 11

Anticholinergics: dont use it at the age over 65
Benztropine (Cogentin)
Trihexyphenidyl

-can be used as monotherapy
-or added to levodopa

Question 12

ADE of Anticholinergics

Answer 12

-dry eyes, increased risk of glaucoma
-dry mouth
-constipation
-less ability to sweat
-delirium in elderly

Question 13

Role of Amantadine

Answer 13

adjunctive to levodopa to treat dyskenisia in PD
but also helps with tremors and rigidity

-patients may become tolerant

-renal dose adjustment

Question 14

What is an unsual side effect specifically of Amantadine?

Answer 14

livedo reticularis

Question 15

How should l-dopa be given?

Answer 15

Sinemet (coformulation with carbadopa)
-immediate release

Question 16

How many mg of carbadopa is required for sufficient l-dopa to get to the brain?

Answer 16

75 mg carbadopa

thats we start with 25/100 TID
-> 25*3 = 75 mg of carbadopa

Question 17

What might interfere with levodopa absorption?

Answer 17

High-protein diet

Question 18

At what dose of levodopa do we rule out PD?

Answer 18

1000 mg

Question 19

ADE of levodopa

Answer 19

-postural hypotension
-hallucinations
-dyskenisia
-akathisia (cant remain still)

Question 20

Characteristis of levo dopa induced ADE

Answer 20

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

Question 21

What might help with Wearing OFF symptoms

Answer 21

-giving smaller and more frequent doses of levodopa
-adding a COMT-inhibitor
-or adding a MOA-B inhibitor
-surgery (brain stimulation)

Question 22

What is the role of COMT-inhibitors in PD therapy?

Answer 22

-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)

Question 23

What is an important counseling point for Entacapone?

Answer 23

Discoloration of urine (brown)

Question 24

Which drug should be given before administering apomorphine?

Answer 24

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

Question 25

Why do antipsychotics worsen PD conditions?

Answer 25

because they block dopamine receptors

Question 26

Which antipsychotics are preferred in patients with PD?

Answer 26

Seroquel (Quetiapine)
Pimavenserin (Nuplazid)
Clozapine

will not worsen Parkinson’s symptoms