PARKINSON'S DISEASE

Question 1

What is Parkinson’s Disease?

Answer 1

Chronic, progressive neurodegenerative condition due to the loss of dopaminergic neurons in the substantia nigra.

Dopamine deficiency in the basal ganglia leads to a movement disorder with parkinsonian motor symptoms

Question 2

Motor symptoms of Parkinson’s Disease

Answer 2

o Hypokinesia
o Bradykinesia
o Rigidity
o Rest tremor
o Postural instability

Question 3

Non-motor symptoms of Parkinson’s Disease

Answer 3

o Dementia
o Depression
o Sleep disturbances
o Bladder and bowel dysfunction
o Speech and language changes
o Swallowing problems
o Weight loss

Question 4

Treatment of Parkinson’s disease for patients whose motor symptoms DECREASE their quality of life

Answer 4

• Levodopa + carbidopa/ benserazide

Question 5

Treatment of Parkinson’s disease for patients whose motor symptoms DON’T AFFECT their quality of life

Answer 5

• Levodopa + adjunct
• Non-ergot derived dopamine-receptor
  o Pramipexole
  o Ropinirole
  o Rotigotine
• Monoamine-oxidase B inhibitors
  o Seligiline
  o Rasagiline
  o Safinamide

Question 6

Non-ergot derived dopamine-receptor agonist

Answer 6

o Pramipexole
o Ropinirole
o Rotigotine

Question 7

Side effects of Non-ergot derived dopamine-receptor

Answer 7

 Impulse disorders
 Sudden onset of sleep
 Hypotension (treated with midrodine or fludrocortisone)

Question 8

Which PD medication is most likely to cause impulse disorders?

Answer 8

Non-ergot derived dopamine-receptor

Question 9

What is hypotension in PD treated with?

Answer 9

midrodine or fludrocortisone

Question 10

Monoamine-oxidase B inhibitors

Answer 10

o Seligiline
o Rasagiline
o Safinamide

Question 11

o Seligiline
o Rasagiline
o Safinamide

Answer 11

Phenylephrine, pseudoephedrine = hypertensive crisis

Question 12

What foods do Monoamine-oxidase B inhibitors interact with?

Answer 12

Interacts with tyramine rich food
* Mature cheese, salami, marmite, yeast, tofu

Question 13

Treatment of Parkinson’s disease for patients who develop dyskinesia or motor fluctuations despite optimal levodopa therapy

Answer 13

• COMT inhibitors
  Entacapone
  Tolcapone

Question 14

COMT inhibitors

Answer 14

Entacapone
Tolcapone

Question 15

Side effects of entacapone

Answer 15

red brown urine

Question 16

Side effects of tolcapone

Answer 16

hepatotoxic
increases sympathetic SFx increase in CD events

Question 17

Treatment of Parkinson’s disease for patients
if symptoms are not adequately controlled with non-ergot derived dopamine receptor agonists as an adjunct

Answer 17

• Ergot-derived dopamine receptor agonist
  o Bromocriptine
  o Cabergoline

Question 18

Ergot-derived dopamine receptor agonist

Answer 18

o Bromocriptine
o Cabergoline

Question 19

Side effects of Ergot-derived dopamine receptor agonist

Answer 19

 pulmonary reactions: report SOB, chest pain cough.
 pericardial reactions: chest pain

Question 20

Withdrawing medication in Parkinson’s Disease

Answer 20

• Do not withdraw medication abruptly
• If person has off periods due to end of dose deterioration – use MR preparations
• Treat nocturnal akinesia with levodopa or oral dopamine receptor agonists as first line option

Question 21

Dopamine pathway

Answer 21

• Dopamine is unable to cross the BBB
• It is important to note that levodopa can be metabolised on either side of the BBB
• 90% of levodopa gets converted into dopamine in the intestinal wall by DDC
  o So it is administered with a DDCI
• SUCH AS carbidopa or benserazide in order to prevent metabolism until after it has crossed BBB
• 5% of levodopa is metabolised by plasma COMT
  o COMT inhibitor
  o Entacapone may be used as an adjunct

Question 22

Levodopa side effects

Answer 22

• Impulse disorders
• Sudden onset of sleep
• Red urine
• Motor complication
• Dyskinesia
• Response fluctuation

Question 23

Impulse disorders

Answer 23

o Pathological gambling
o Binge eating
o Hypersexuality

Question 24

How is sudden onset of sleep treated?

Answer 24

modafinil - review every 12 months
o DVLA needs to be informed, pt advised not to drive

Question 25

How is nocturnal akinesia treated?

Answer 25

1. Levodopa or dopamine-receptor agonist e.g. Rotigotine

Question 26

How is postural hypotension treated?

Answer 26

1. Midrodine
2. Fludrocortisone

Question 27

How is Rapid eye movement sleep behaviour disorder treated?

Answer 27

Clonazepam [unlicensed]
Melatonin [unlicensed]

Question 28

How is Psychotic symptoms treated?

Answer 28

1. Quetiapine [unlicensed]
2. Clozapine

For hallucination and delusion

Other antipsychotics such as phenothiazines and butyrophenones can worsen motor features of PD

Question 29

How is drooling of saliva treated?

Answer 29

Glycoyyronium bromide

Question 30

How is Impulse control disorder treated?

Answer 30

Apomorphine

Question 31

How is dementia treated?

Answer 31

1. Rivastigmine caps and oral solution
2. Memantine

Question 32

Treatment of advanced PD

Answer 32

Apomorphine

Question 33

Apomorphine

Answer 33

• Intermitten
  t injection or s/c infusion
• Assessment of cardiac risk factors and ECG monitoring due to risk of serious arrhythmias due to QT prolongation

Question 34

Nausea and vomiting in Parkinson’s Disease

Answer 34

N+V – domperidone
o Restricted in those weighing less than 35kg