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PHRM 845 > Parkinson's > Flashcards

Parkinson's Flashcards

1
Q

Impact of PD

A
  • Financial burden. need for care, changes in cognition/psychology of patient
  • Affects speech and tremor
  • Mean duration of illness: 15 years
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2
Q

PD Presentation

A
  • Resting tremor: most common first symptom, usually asymmetric
  • Rigidity: muscle tone increase in flexor and extensor muscles (resistance to passive movements)
  • Bradykinesia: difficulty with daily activities like writing, shaving, eating, dressing
  • Postural instability: loss of postural reflexes

“TRAP” = primary criteria for diagnosis

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3
Q

Essential Tremor

A
  • Not a sign of Parkinson’s
  • Symmetric
  • Tremulous hand action along with head and voice tremor
  • Large tremulous handwriting
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4
Q

Other PD Features

A
  • Masked facies
  • Hypophonia
  • Drooling
  • Depression
  • Fatigue
  • Slow gait
  • Difficulty with ADLs
  • Pain
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5
Q

PD Advanced Symptoms

A
  • Dysphagia
  • Falls
  • Freezes in gaits
  • Dementia
  • Psychosis
  • Postural hypotension
  • Bladder and anal dysfunction
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6
Q

PD Non-Pharm

A
  • Patient/caregiver education
  • Support/counseling: peers, professional, legal, occupational
  • Exercise
  • Nutrition
  • Surgery
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7
Q

Psychological Support + PD

A
  • Depression
  • Limited social functioning
  • Poor QoL (severe disease)
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8
Q

PD + Safety Devices

A
  • Grab bars
  • Bath seats
  • Emergency alert systems
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9
Q

PD Pharmacotherapy Approach

A
  • Plan for short and long term relief/management
  • Manage potential SE
  • Provide symptom control for daily living
  • Timing of inital therapy based on patient functional ability
  • Titrate treatment over time to maximize therapeutic response
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10
Q

PD Treatment Mechanisms

A
  • Increase endogenous DA: inhibit peripheral metabolism, COMT, or central/peripheral MAO-B metabolism
  • DA agonists: D1, D2, D3, partial agonists
  • Adenosine A2a
  • Anticholinergic: helps with tremor and rigidity (often not preferred in geriatrics)
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11
Q

Surgical Therapy + PD

A
  • Deep Brain Stimulation (DBS)
  • Most commonly performed PD surgery in America
  • Implant electrode connected to a pulse generator that delivers current to thalamus, globus pallidus interna, or subthalamic nucleus
  • Adjust amplitude, frequency, and pulse width
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12
Q

PD + Psychosis

A
  • 15-40% experience psychosis
  • DA or ACh drug induced possibility
  • Look for triggers and minimize polypharmacy
  • Reduce anti-PD medications, add atypical antipsychotics (Seroquel)
  • Add cholinesterase inhibitor (dementia)
  • May consider pimavanserin
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13
Q

Atypical Antipsychotics

A
  • Tight binding to DA antagonists could worsen condition
  • Quetiapine (sedation), clozapine, pimvanserin (titrate as tolerated)
  • Black box: dementia
  • Acetyl-cholinesterase inhibitors: Donepezil, rivastigmine also options
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14
Q

Depression + PD

A
  • Occurs in 25-40% of population
  • Difficult to diagnose (symptom overlap)
  • Insomnia, fatigue, psychomotor slowing, decreased libido
  • Evaluate electrolytes, thyroid, hypogonadism
  • SSRI therapy if depression is significant
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15
Q

MAO-B Inhibitors

A
  • May delay the need to begin levodopa therapy by 9 mo
  • Inconclusive on if selegiline slows PD progression
  • Use in patients with intact cognition and experiencing “wearing-off” with L-dopa
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16
Q

Selegiline

A
  • Dose: 10 mg/day
  • Use with L-dopa to reduce its dose by ~50%
  • AE: Minimal, insomnia and jitters
  • Rare 5HT syndrome with use with SSRIs
17
Q

Rasagiline

A
  • Azilect
  • Selective MAO-B inhibitor
  • 5x more potent than selegiline
  • 0.5-1mg/day when used with levodopa
  • CYP1A2 metabolization
  • Approved for early PD patients monotherapy
18
Q

Levodopa

A
  • Starting Dose: 200-300 mg/day, Max: 800-1600 mg/day
  • Titrate 100mg/week
  • Carbidopa: 75 mg/day to prevent peripheral AE
  • Several combination products available in various formulations
19
Q

Carbidopa/Levodopa

A
  • Most common prescription for PD symptoms
  • Virtually all PD patients experience a clinical benefit with the medication
  • After sustained usage, effects usually wear off between doses
20
Q

Carbidopa/L-dopa Complications

A
  • Motor flunctuations: “on-off”
  • Non-motor fluctuations: sensory, cognitive, psychiatric
  • Diminishing efficacy
  • Refractory loss of balance
  • Cognitive deficiency
  • Episodic vs continual dosing
21
Q

“Wearing-Off”

A
  • Benefits from each L-dopa dose gets shorter over time and symptoms return between doses
  • Disease could be worsening or more frequent dosing could be needed
  • Seen with prolonged usage (4-5+ years)
22
Q

Wearing-Off Strategies

A
  • Increase L-dopa dose or number of doses
  • Add DA-agonist or increase its dose
  • Use COMT-I
23
Q

DDA

A
  • Direct DA Agonists
  • Use alone or in conjunction with carbidopa/levodopa
  • Pramipexole or ropinirole are most commonly used
24
Q

DA Agonists Benefits

A
  • Less risk of motor complications and dyskinesias compared to carbidopa/levodopa
  • Improve effects and durations when used in combination with levodopa/carbidopa
  • May be beneficial as a monotherapy in a early disease patient
  • Potentially neuroprotective compared with levodopa/carbidopa
25
Q

DA Side Effects

A
  • N/V
  • Orthostasis
  • Psychosis
  • Narcolepsy
  • *Occurs in higher doses or rapid titrations**
  • Often a limiting factor for the use of these medications
26
Q

Pramipexole (D2)

A
  • Dose: 0.125 mg TID, titrate every 5-7 days as toelrated
  • 1.5mg/day is as effective as higher doses and has less SE
  • Adjust for renal insufficiency
27
Q

Ropinirole

A
  • D3 > D2 > D4
  • Dose: 0.25 TID and titrate by 0.25 every week
  • Max: 25 mg/day
  • Metabolized by CYP1A2
28
Q

Transdermal DA

A
  • Rotigotine (Neupro)
  • More continuous DA stimulation
  • Less possibility of motor fluctuation and dyskinesias
  • AE: application site rxn, nausea, somnolence, narcolepsy
  • Allows for lower L-dopa doses
29
Q

COMT-I

A
  • ONLY use as adjunct to carbidopa/levodopa
  • NO ROLE MONOTHERAPY
  • Indicated for those experiencing wearing off
  • Comtan (entacapone) or Tasmar (tolcapone)
  • *Latter has LFT issues, don’t really use**
  • Increase L-dopa levels in brain and reduce its burden for more consistent and continuous levels
30
Q

Entacapone

A
  • Dopaminergic effects most common
  • Allows for reduced doses of L-dopa
  • Brown/orange fluid discoloration is common
  • No hepatotoxicity evidence
  • SE: diarrhea, orthostasis
  • Dose: 200mg up to 8x a day used with Carbidopa/levodopa
31
Q

Amantadine

A
  • Monotherapy for newly diagnosed patients for mild tremor
  • Exact MoA unknown
  • Limit use with elderly due to neuropsychiatric effects (confusion, nightmares, hallucinations)
  • Withdrawal slowly to avoid worsening PD symptoms
32
Q

Anticholinergics

A
  • Option for younger patients with mainly resting tremor
  • Options: Trihexyphenidyl (Artane), Benztropine (Cogentin)
  • AE: memory impairment, agitation, confusion, hallucination, antimuscarinic effects, dysphoria
  • AE limit its use

PHRM 845 (5 decks)

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