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p3 year :) > parkinson's > Flashcards

parkinson's Flashcards

1
Q

benztropine MoA

A

anticholinergic –> dec ACh activity –> rebalance ACh with lower DA levels –> dec s/s due to DA deficiency

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2
Q

benztropine CI

A

BEERS –> CI elderly bc anticoholinergic

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3
Q

trihexyphenidyl MoA

A

anticholinergic –> dec ACh –> rebalance with dec DA

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4
Q

trihexyphenidyl CI

A

BEERS –> CI elderly bc anticholinergic

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5
Q

anticholinergic MoA

A

antimuscarinic

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6
Q

anticholingeric AEs

A

*link to cognitive impairment/decline (inc dementia risk — recall from last unit!!)

  • blind as a bat (mydriasis)
  • dry as a bone (mouth, skin, urinary retention, constipation)
  • hot as a hare (fever)
  • mad as a hatter (depressed, agitated)
  • red as a beet (flushed skin)

opposite of SLUDGE cholinergic effects
S: sialorrhea
L: lacrimatin
U: urination
D: defecation
G: GI emesis, diarrea
E: emesis

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7
Q

anticholinergic place in therapy

A

monotherapy or combo therapy

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8
Q

levodopa MoA

A

synthetic precursor to DA
**CROSSES BBB –> DA does NOT!! –> hence why we cannot just give dopamine

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9
Q

levodopa place in therapy

A

gold standard!!

usually combo therapy with dopa decarboxylase inhibitor, can be monotherapy if IN

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10
Q

levodopa PKPD

A
  • transported by large amino acid transporter in GI and BBB –> THEREFORE will dec absorption if take with high protein meal
  • metabolized by LAAD into DA
  • very little reaches CNS without a decarboxylase inhibiot (carbidopa)
  • renal elim

**HAVE TO GIVE WITH CARBIPODA in order to inc the concentrations of levodopa to reach CNS!!

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11
Q

levodopa and food

A

take on empty stomach or do not change how have been taking it
–> taking with high protein meal –> dec absorption bc competiting for the large amino acid transporters in GI and BBB

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12
Q

levodopa CI

A
  • breast feeding
  • closed angle glaucoma
  • melanoma (in Canada)
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13
Q

levodopa AE

A

**dose-dependent!!

  • dyskinesia (twisting/squirming)
  • “on-off” phenomena, dec effectiveness overtime
  • psychiatric disturbances, vivid dreams
  • GI (N)
  • orthostatic hypotension
  • saliva, sweat, urine discoloration (orange)
  • **NMS (neuroleptic malignant syndrome) with abrupt D/C –> fever, AMS, muscle rigidity, autonomic dysfunction
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14
Q

levodopa DDI

A
  • dopamine antgonists (metoclopramide, antipsychotics)
  • NON-SELECTIVE MAO-Is
  • high protein meal
  • iron salts –> separate admin by 2 hours
  • pyridoxine (B6) –> inhibit efficacy
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15
Q

levodopa dose

A

200-300 mg/day –> 100mg BID or TID, inc by no more than 100mg per week –> no max dose

almost always give with dopa-decarboxylase inhibitor

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16
Q

carbidopa MoA

A

noncompetitive dopa decarboxylase inhibitor

L-dopa –dopa decarboxylase–> inactive peripheral L dopa

therefore –> inhibit breakdown of peripheral L-dopa –> inc DA levels in peripheray –> OHHH hency why bradykinesia and tremor start peripherally

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17
Q

carbidopa effects

A

increase absorption of levodopa AND half life of levodopa!! –> gives it enough time to go into CNS and become DA

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18
Q

carbidopa place in therapy

A

NO PHARMACOLOGIC EFFECTS ON OWN —> ALWAYS COMBO THERAPY!!

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19
Q

carbidopa PKPD

A
  • not cross BBB
  • renal elim
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20
Q

carbidopa CI

A
  • pregnancy
  • lactation
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21
Q

Sinemet

A

carbidopa/levodopa

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22
Q

Sinemet dosing

A

NEED to keep carbidopa dose at 70-100 mg/day minimum
- allows for saturation of enzyme to prevent breakdown
- prevents levodopa AE of N/V

EXCEPTIONS:
low doses can be tolerated –> Sinemet 25/100mg BID

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23
Q

Sinemet CR benefits

A
  • dec total off time
  • dec dosing frequency
  • if take at bedtime, can dec morning rigidity
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24
Q

Sinemet CR cons

A
  • decreased bioavalibilty vs IR (25% of IR)
  • delayed onset of effect when taken in morning (peak at 2 hours instead of 30 min)
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25
Q

how to overcome Sinemet CR delayed onset

A
  • supplemental IR Sinemet in morning
  • set alarm 30-60min early, take dose, go back to bed
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26
Q

how to change from IR to CR

A

recall: CR 25%F vs IR, therefore CR uses higher doses

  • start 50% reduction in FREQUENCY!! (ex: QID –> BID)
  • 25% increase in dose per day
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27
Q

Duopa

A

carbidopa/levodopa intestinal gel

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28
Q

Duopa administration

A
  • PEG-J tube (into jejunum) through wearable pump
    **bypasses variable GI absorption of the oral formulations (high protein meal, dec F, …)
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29
Q

Duopa use

A

usually for advanced parkinsons (significant off time, or significant dyskinesia) –> achieves more consistent L-dopa levels

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30
Q

Duopa dose

A

1 cassette (2000mg) per day, administered over 16 hours

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31
Q

how to dose convert to Duopa

A

CR –> IR –> Duopa
** clinicla trials only figured out dose conversion from IR**

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32
Q

Duopa AEs

A
  • normal carbidopa/levodopa AEs (N/V, dyskinesia, NMS, vivid dreams, …)
  • PEG-J: infection, bleeding, tube clog/dislodge
  • tube needs cleaning and care
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33
Q

Inbrija

A

levodopa powder –> ORAL inhalation!!

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34
Q

Inbrija indication

A

intermittent treatment for off episodes, also treated with carb/levo
**advanced parkinson’s
**NOT replacement for PO carb/levo

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35
Q

Inbrija dosing

A

prn for off symptoms up to 5 times a day

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36
Q

Inbrija AE

A
  • somnolence
  • hallucinations
  • dyskinesia
  • cough
  • nausea
  • URI
  • sputum discoloration
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37
Q

Inbrija CI

A

non-selective MAOi use within 2 weeks

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38
Q

Inbrija not recommended in

A
  • asthma
  • COPD
  • chronic underlying lung disease
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39
Q

COMT inhibitors

A
  • tolcapone
  • entacapone
  • opicapone
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40
Q

COMT inhibitor MoA

A
  • reversible, selective inhibition of COMT –> therefore inhibit L-dopa breakdown –> therefore inc L-dopa levels –> inc DA
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41
Q

COMT inhibitior place in therapy

A

NEED L-DOPA –> MUST be in combination with levodopa

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42
Q

COMTi DDIs

A
  • drugs metabolized by COMT (APOMORPHINE, bitolterol, dobutamine, dopamine, epinephrine, isoetharine, isoproterenol, methyldopa, norepinephrine)
  • non-selctive MAOis
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43
Q

entacapone MoA

A
  • COMTi –> prevent L-dopa breakdown –> inc L-dopa
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44
Q

entacapone PKPD

A
  • acts in periphery
  • shorter half life than other COMTis
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45
Q

entacapone dose

A

200mg WITH EACH DOSE of carb/levo –> MDD: 8 times/day

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46
Q

entacapone AEs

A
  • similar to levodopa (bc inc leovodopa)
  • brown/orange urine
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47
Q

Stalevo

A

carbidopa/levodopa/entacapone –> always 200mg entacapone in these doses

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48
Q

tolcapone MoA

A
  • COMTi –> therefore inhibit L-dopa breakdown –> inc L-dopa
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49
Q

tolcapone PKDP

A
  • central and peripheral activity
  • food dec bioavliability!!
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50
Q

tolcapone CI

A
  • hepatic disease –> tolcapone-induced hepatocellular injury!!!)
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51
Q

tolcapone AE

A
  • **hepatocellular injury
  • delayed onset diarrhea
  • similar to levodopa
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52
Q

tolcapone monitoring

A

LFTs –> watch for inc, must sign consent

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53
Q

tolcapone place in therapy

A

rarely used anymore
- older
- hepatocellular injury

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54
Q

tolcapone dose

A

100mg TID

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55
Q

opicapone MoA

A

COMTi

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56
Q

opicapone PKDP

A
  • DEC ABSORPTION WITH moderate fat/calorie meal –> dec AUC and Cmax (NOT high protein meal, be careful!!)
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57
Q

opicapone dosing

A

ONCE DAILY
- 50mg QHS (bedtime)
- do not eat one hour before/after

58
Q

opicapone CI

A
  • nonselective MAOI use
  • catecholamine secreting neoplasm (pheochromocytoma, paraganglioma)
  • severe hepatic impairment
59
Q

opicapone caution

A
  • mild-mod hepatic impairment
60
Q

opicapone AE

A
  • similar to levodopa
  • similar to COMTis
61
Q

central and peripheral MAO-B inhibitors

A
  • selegiline
  • rasagiline
  • safinamide
62
Q

MAO-B inhibitior MoA

A
  • noncompetitive, selective antagonist of monoamine oxidase type B –> dec breakdown of dopamine (only DA, not others like NE) (selective therefore no tyramine considerations)
  • decrease free radical production –> delays need for L-dopa by 9 months
  • inc peak of L-dopa –> dec L-dopa doses by 50%
  • symptoms control
63
Q

MAO-Bi place in therapy

A
  • monotherapy or adjunctive therapy
64
Q

which MAO-B is potentially disease-modifying?

A

rasagiline

65
Q

selegiline MoA

A

MOA-B inhibitor –> prevents dopamine breakdown –> increase endogenous DA

66
Q

selegiline types

A
  • Eldepryl –> po
  • Zelapar –> transbuccal
67
Q

selegiline indication

A

labeled: adjunctive ONLY
studies: can be mono

68
Q

selegiline PKPD

A
  • high F
  • *crosses BBB
  • ***ACTIVE METABOLITES –> methyldeprenyl, amphetmaine, methamphetamine –> linger for weeks, can show (+) amphetamine tox
  • slow elimination
69
Q

selegiline dosing

A

Eldepryl (po) –> 5mg qd-bid
Zelapar (dissolving tab) –> 1.25mg qd up to 2.5mg qd, **no food/drink 5 minutes before/after

70
Q

selegiline CI (not absolute)

A
  • dementia, severe psychosis
  • concomitant use of meperidine, tramadol, methadone, propocyphene –> bc amphetamine-like metabolities
71
Q

selegiline AEs

A

**dopagenergic (makes sense bc dec DA breakdown –> therefore inc DA)
- CNS, GI
- HTN crisis
- serotonin syndrome
- *insomnia, jittery, HA

Zelapar (ODT)
- irritation of buccal mucosa

72
Q

selegiline DDIs

A
  • MAOI (nonspecific)
  • TCA, SSRI, SNRI, DXM –> serotonin syndrome
  • tyramine containing foods when doses >10mg (oh??)
  • sympathomimetics
73
Q

which is preferred between selegiline and rasagiline ?

A

rasagiline
- no amphet like active metabolites
- potentially disease modifying

74
Q

rasagiline place in therapy

A

monotherpay
combo therapy

75
Q

rasagiline dose

A

with levodopa: 0.5mg qd
monotherapy: 1mg qd

76
Q

rasagiline AEs

A

monotherapy
- HA
- arthralgia
- GI
- falls

with levo:
- dyskineia
- GI upset
- HA
- weight loss
- arthralgia
- orthostasis –> most common during first two months of treatment

77
Q

rasagiline DDIs

A
  • ciprofloaxacin (metabolized by 1A2)
  • MAOIs non-specific (2 week washout)
  • TCA, fluoxetine (5 week washout)
  • tryamine containing foods
  • sympathomimetics
78
Q

rasagiline CIs

A
  • meperidine, tramadol, methadone, propxyphene, DXM
  • St. John’s wort
  • mirtazapine
  • cyclobenzaprine (serotonin syndrome)
  • vasoconstrictors (HTN crisis)
79
Q

safinamide MoA

A

MOA-B inhibitor –> dec dopamine breakdown –> inc DA

  • Na and K channel blocker, dec glutamate –> all inc inhibition (good bc low inhibition from DA)
80
Q

safinamide indication

A
  • adjunctive to levodopa, for off s/s
81
Q

safinamide dosing

A

50mg po qd – > 100mg qd

82
Q

safinamide PKPD

A
  • renal elim
  • *hepatic metabolism
83
Q

safinamide dose reduction

A

**Hepatic impairment –> 50mg qd max dose!

84
Q

safinamaide CI

A
  • cirrhosis (child-pugh C)
85
Q

safinamide DDI

A
  • sertonergic drugs (opioids, SSRI, SNRI, TCA, amphet, St John’s wort)
  • sympathomimetics (HTN)
  • DXM (bizarre behavior)
  • substrates of BCRP
86
Q

safinamide AE

A
  • dyskinesia
  • hallucination
  • psychosis
  • behavior change
  • nausea
  • daytime somnolence
  • retinal ptahology
  • **NMS if abrupt withdrawal!!!
87
Q

amantadine options

A

Symmetrel (IR)
Gocovri (ER)
Osmolex (ER)

88
Q

amantadine MoA

A

inc DA release (from storage sites), dec DA reuptake, inhibit NMDA (excitatory) receptors
*poorly understood

89
Q

amantadine indication

A

**levodopa-induced dyskinesia!!! –> add on to levo

  • dec rigidity, tremor, bradykinesia, dyskinesia
90
Q

amantadine PKPD

A
  • good F
  • renal elim –> DOSE ADJUST RENAL IMPAIRMENT!!
91
Q

amantadine dosing

A

Symmetrel (IR): 300mg/day divided doses

Gocovri (ER): 137mg qd –> 274mg qd

Osmolex (ER): 129mg qd –> 322mg qd

92
Q

amantadine CI

A
  • CHF
  • orthostatic hypotension
  • peripheral edema

**bc inc fluid retention

93
Q

amantadine AE

A
  • orthostatic hypotension/dizzy/**fall
  • hallucination
  • sedation
  • anticholinergic (hence fluid retention)
  • **livedo reticularis –> reversible mottling of skin with lower extremity edema
  • NMS with abrupt d/c
94
Q

amantadine DDI

A
  • Flumist (LAIV) –> dec vaccine efficacy
  • quinine/quinidine, HCTZ, triamterene
95
Q

which drug is for intermittent off symptoms

A

Inbrija (levodopa orl inhalation)

96
Q

which drug is for for levodopa induced dyskinesia

A

amantadine

97
Q

which drugs are monotherpay

A
  • Sinemet
  • Sinemet CR
  • Duopa
  • Stalevo
  • rasagiline

**all others need treatment with levodopa too!!!

98
Q

dopamine agonists

A

byspass endogenous DA system –> activate post-synaptic receptors

99
Q

dopamine agonists

A

D2: apomorphine
D2 and D3: pramipexole, ropinirole
D2, D3, D1: rotigotine

100
Q

dopamine agonist use

A

*monotherapy –> in younger, healthier patients

  • reduce risk of developing motor complications (wearing off effects) vs levodopa when used an monotherapy!!!

*combination therapy –> deterioation in response to levodopa
- when levodopa has fluctuations in response, or unable to tolerate inc doses of levodopa –> dec off time, dec dyskinesia

101
Q

dopamine agonist vs levodopa

A

**more frequent non-motor side effects vs levo –> especially in older/frail patients
- impulsive behaviors, psychosis
- N/V, vivid dreams, daytime sedation, orthostatic hypotension

102
Q

apomorphine MoA

A

stimulates postsynaptic D2 receptors

103
Q

apormorphine indication

A

advanced PD
prn for off episodes

104
Q

apomorphine dose

A

TEST DOSE: 2mg SQ, under medical supervision
- MONITOR BP beofre, 20min, 40min, 60min

prn for off periods, MDD: 6mg, TID dosing

*rotate injection sites

105
Q

apomorphine PKPD

A

**rapid onset of action –> hence why for breakthrough

106
Q

apomorphone pre-treatment

A

**antiemetic
- 3 days before, then continue for 2 months, then reassess
- NOT dopamine antagonist or antidopaminergic ( metocloproamide, prochlorpazine)

107
Q

apomorphine AE

A
  • N/v
  • dizzy
  • somnolence
  • chest pain/pressure
  • dyskinesia
  • falls
  • yawning
  • rhinorrhea
108
Q

apomorphine DDI

A
  • dopamine antigonists –> inc hypotensive effects
  • QT prolongation drugs (additive effects)
  • DA antiaognists (antiphyschotics)
109
Q

pramipexole MoA

A

D2 and D3 dopamine agonist

110
Q

pramipexole PKPD

A
  • renal elimination –> DOSE REDUCE if CrCl < 60!!
111
Q

pramipexole dose

A

IR: tid
ERL qd

112
Q

pramipexole DDI

A
  • cimetidine – inhibitor of renal tubular secretion
113
Q

ropinirole MoA

A

D2 and D3 dopamine agonist

114
Q

ropinirole PKPD

A

metabolized by 1A2

115
Q

ropinirole dose

A

IR: tid
XL: qd

116
Q

ropinirole CI

A
  • abrupt discontinuation (all of this drug class)
  • hepatic disease
117
Q

ropinirole DDI

A

**CYP 1A2 inhibitors –> inc concentration
- cimetidine, cipro, clarithro, diltiazem, erythro, fluvoxamine, omeprazole, ritoniavir
CYP 1A2 inducers –> dec concentration
- carbamazepine, phenobarb, phenytoin, rifampin, ciagrette*
smoking will dec drug effect!!

118
Q

rotigotine MoA

A

D1, D2, D3 agonist –> primarily D2

119
Q

rotigotine dose

A

**transdermal patch!!
start 2mg/24 hours –> 4mg minimum effective dose –> 6mg MDD

120
Q

rotigotine precaution

A
  • heat, MRI –> skin burns
  • sulfite sensitivity –> anaphylaxis
121
Q

rotigotine AE

A
  • CNS
  • GI
  • peripheral edema
    -**application site reaction
122
Q

rotigotine DDI

A
  • dopamine antagonists –> antipsychotics, metoclopramide
123
Q

adensoine A2A receptor funciton

A

GPCR abundant in basal ganglia –> caffeine is a competitive antagoinst –> functions to regulate glutamate (excitatory) and dopamine (inhibitory) release

124
Q

adenosine A2A receptor function in parkinsons

A

overactivation of A2A receptor pathway –> inhibition of motor function

therefore, we want to inhibit A2A receptor function!

125
Q

istradefylline MoA

A

adenosine A2A receptor antagonist –> dec overactivation of A2A –> prevent inhibition of motor function (bradykinesia)

126
Q

istradefylline indication

A

combo therapy, for off episodes –> reduces off time, effective after 4 weeks

127
Q

istradefylline dose

A

20mg po every morning!
max 40mg

128
Q

what to dose adjust istradefylline for

A
  • concamitant smoking –> inc dose
  • mod hepatic impairment –> dec dose
129
Q

istradefylline AE

A
  • **dyskinesia
  • insomnia
  • hallucinations
  • dizzy
130
Q

istradefylline metabolism

A

3A4 and 1A1

131
Q

istradefylline DDI

A

with strong 3A4 inhibitors (inc conc) –> MDD 20mg

avoid use with strong 3A4 inducers (dec conc)

132
Q

best non-pharm option

A

exercise!!

133
Q

how to treat PD psychosis

A
  1. exclude infection, electrolyte imbalance, hypoxemia
  2. D/C and dec doses of meds –> anticholinergics, amantadine, selegiline
  3. treat with atypical antipsychoitics
134
Q

PD atypical antipsychotics

A
  • quetipine
  • clozapine
  • pimavanserin (Nuplazid)
135
Q

quetipine and clozpine MoA

A

block both serotonin and DA –> blocking DA counteractive to PD treatment, therefore good that also block serotonin

136
Q

pimavanserin MoA

A

5HT2A/2C inverse gonist –> blocks serotonin –> does NOT block DA –> good bc not counteracting PD meds!!!

increases slow-wave sleep

137
Q

pimavanserin indication

A

**specifically parkinsons –> hallucinations and delusions

138
Q

pimavanserin BBW

A

inc death in eldery patients with demetia who are treated with antipsychotic drugs

139
Q

pimavanserin AE

A
  • QT prolongation
  • peripheral edema
  • nausea
  • confusion
140
Q
A

p3 year :) (5 decks)

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