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701 > Parkinson's > Flashcards

Parkinson's Flashcards

1
Q

Parkinson’s pearls

A
  • Dopamine deficiency (loss of balance with ACh)
  • Loss of dopaminergic cells in SNc/basal ganglia AND formation of Lewy bodies
  • Mostly male
  • Average age of onset = 62
  • Rural life increases risk (pesticides?)
  • INVERSE correlation between smoking and caffeine for PD development
  • 30-80% of nigral cell death before disease manifests
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2
Q

Diagnosis

A

Bradykinesia (slow/difficult movement) and at least 1:
- Limb rigidity (usually starts unilateral)
- Resting tremor (usually starts unilateral)
- Postural instability

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3
Q

What drugs can cause parkinsonism?

A
  • 1st generation antipsychotics
  • Antiemetics (reglan, compazine)
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4
Q

Anticholinergics

A

Benztropine, Trihexyphenidyl
- Avoid in >65 y/o
- Linked to cognitive decline/impairment

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5
Q

Levodopa

A
  • Gold standard*
  • Precursor to dopamine, crosses BBB
  • Take on empty stomach to maximize abs.
  • Be consistent with administration (w,w/o food)
  • CI in breast-feeding, closed-angle glaucoma
  • ADE dyskinesia, GI, orthostatic HTN, waste discoloration, psychiatric disturbances
  • Stops working over time**
  • DDI with MAOis, iron, pyridoxine, DAs
  • Start 200-300 mg/day in divided doses
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6
Q

Carbidopa

A
  • Does not cross BBB
  • useless alone, only helps deliver levodopa to brain
  • CI in pregnancy, lactation
  • Maintain 70-100 mg/day when in L-dopa combo
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7
Q

Sinemet

A
  • 1:10 or 1:4 ratio of carbidopa/levodopa
  • Sinemet CR has decreased bioavailability compared to IR (give 25% more)
  • CR has decreased off time, but delayed onset (can supplement IR)
  • Start decreasing frequency to switch IR -> CR
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8
Q

Duopa

A
  • Carbidopa/Levodopa intestinal gel - PEG-J tube
  • Mostly for advanced PD to achieve more consistent L-Dopa levels (less off time)
  • Pts must convert to oral IR first
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9
Q

Inbrija

A
  • Levodopa powder for inhalation
  • Not replacement for PO Carb/Levo but used for off episodes
  • Avoid in respiratory disorders
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10
Q

COMT inhibitors

A

Tolcapone, Entacapone, Opicaopone
- prevents breakdown of L-Dopa
- no effect in absence of L-dopa
- DI with non-selective MAOis

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11
Q

Entacapone (Comtan)

A
  • Shorter t1/2
  • Give 200mg with EACH DOSE of levodopa/carbidopa (up to 8 times/day)
  • May cause brown/orange urine
  • Stalevo is a combo product of entacapone/levodopa/carbidopa
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12
Q

Tolcapone (Tamsar)

A
  • Contraindicated in hepatic disease
  • Rarely used due to hepatocellular injury (inc. LFTs)
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13
Q

Opicapone (Ongentys)

A
  • New (4/2020)
  • Absorption decreased with big meal
  • Once daily dosing, do not eat within 1 hour
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14
Q

MAOis

A

Selegiline, Rasagiline, Safinamide
- Decrease breakdown of dopamine
- Increase L-Dopa peaks, less dosing needed
- Can be used as monotherapy or adjunctive
- Tyramine reaction (cheese, wine)

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15
Q

Selegiline

A
  • Labeled indication for adjunct, but data supports monotherapy
  • 3 active metabolites, lingers for weeks
  • ADE insomnia, jitteriness
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16
Q

Rasagiline (Azilect)

A
  • Potentially DISEASE MODIFYING***
  • 0.5 mg QD with levodopa
  • 1 mg QD for monotherapy
17
Q

Safinamide (Xadago)

A
  • Adjunctive therapy for wearing off sx.
  • Newer agent
  • Na and K channel blocker, dec. glutamate
  • 90% renal
  • hepatic metabolism
18
Q

Amantadine

A
  • MOA poorly understood
  • Decrease rigidity, tremor, bradykinesia, and L-Dopa-induced dyskinesia**
  • Adjust dose with renal impairment
  • ADE peripheral edema, livedo reticularis
19
Q

Dopamine agonists

A

Apomorphine, Pramipexole, Ropinirole, Rotigotine
- Can be used as monotherapy
- Reduce risk of developing motor complications compared to L-Dopa
- Used as adjunct for L-Dopa loss of effect
- Non-motor ADE more common compared to L-Dopa
- Impulsive behaviors, psychosis, N/V, vivid dreams, orthostatic HTN, daytime sedation

20
Q

Pramipexole (Mirapex)

A
  • Renal dosing
21
Q

Ropinirole (Requip)

A
  • CI in hepatic disease
  • Do not abruptly discontinue, taper
  • CYP1A2 DIs
22
Q

Rotigotine (Neupro)

A

-Transdermal patch
- Causes skin burns in MRI, caution with heat
- Careful with sulfite sensitivity (has metabisulfite)
- Application site reaction

23
Q

Apomorphine (Apokyn)

A
  • Used in advanced PD “as needed” for off episodes (not monotherapy)
  • 2mg SC test dose under medical supervision required, monitor BP
  • Pre-treat with antiemetic (NOT 5HT3 -> hypotension)
  • Rapid onset of action
  • 40 minute terminal t1/2
24
Q

Istradefylline (Nourianz)

A
  • Adenosine A2A receptor blocker (motor inhibition is caused by overactive adenosine A2A)
  • Used for off episodes of carbidopa/levodopa (adjunct)
  • Dosage adjustment for concomitant tobacco smoking
  • DDi with CYP3A4
25
Q

Non-pharm PD treatments

A
  • Exercise therapy the best
  • Surgery (deep brain stimulation)
  • Nutrition (fluids, fiber, omega-3 fatty acids)
  • Occupational/fall therapy

701 (11 decks)

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