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Parkinson's Disease Flashcards

1
Q

True or False - Parkinsons Disease is curable.

A

False - it is not.

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2
Q

What is the neurotransmitter that causes of PD?

A

Deficiency in dopamine in brain stem (substantia nigra)

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3
Q

Motor symptoms of PD

A

“TRAP”
T- tremors (at rest)
R - rigidity (stiff legs, ams, trunk joints)
A - akinesia (slow movement/lost dexterity)
P - postural instability (gait, cant walk, falls)

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4
Q

Non-Motor symptoms of PD

A

Constipation
incontinence
insomnia
depression/anxiety
drooling
sialorrhea
masked face
muffled speech
bent over body

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5
Q

Who are the members of a multidisciplinary health care team to treat someone with PD?

A

SLP
Occupational therapist
Physiotherapist
Dietitian

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6
Q

Treatment for MILD PD?

A

Irreversible MAO-b inhibitors
RASAGILINE
SELIGILINE

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7
Q

treatment for Moderate-Severe PD

A

1st line: levodopa
OR
Dopamine agonists: bromocriptine, pramipexole, ropinirole, rotigotine patch)

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8
Q

In which patients are dopamine agonists considered 1st line?

A

If patients are < 60 years old, and they accept the AE of dopamine agonists. If ineffective or intolerant, then switch to Levodopa.

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9
Q

DDIs with MAOB-i?

A

Drugs that can cause serotonin syndrome: triptans, SSRIs

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10
Q

What is the Wear off phase of Levodopa? (end dose)

A

a predictable decline in the effectiveness of Levodopa at the end of the dosing interval, occurs after 3-5 years after taking Levodopa.

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11
Q

What is dyskinesia?

A

abnormal and involuntary movement usually in the legs; can occur at the beginning or end of levodopa response cycle

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12
Q

How to manage dyskinesia due to levodopa or a dopamine agonist?

A

think of dyskinesia as overdose/toxicity of levodopa.
1. decrease dose of levodopa or dopamine agonist
or
2. switch to a different dopamine agonist
3. discontinue any anticholinergics, MAOi, or entacapone if worsening symptoms

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13
Q

how to manage the waring off effect or the on-off fluctuation effect from levodopa?

A
  1. increase frequency of levodopa
  2. change to CR (extends from 60 min to 90 min)
  3. Add Entacapone with Sinemet CR for further extension (~1 hr)
  4. Add on a dopamine agonist (bromo) or add rasagiline, amantadine for dyskinesia control.
  5. adjust diet - reduce protein intake, mix levodopa in water for a quick rescue
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14
Q

“Wear-Off” (End-Dose Effect) and “On-Off” Fluctuations

A

Sudden freezing episodes or loss of motor control due to fluctuations in drug efficacy.

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15
Q

Which types of food interferes with levodopa absorption?

A

protein competes with levodopa absorption

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16
Q

Should levodopa be taken with or without food?

A

with food

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17
Q

Patient X comes to the pharmacy asking for which medication to take for her nausea/vomiting. Her medical history includes Parkinson’s Disease. What is the drug of choice?

A

Domperidone - preferred because it does not cross the blood brain barrier, avoiding EPS symptoms

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18
Q

Dose considerations of domperidone to treat nausea or vomiting caused by levodopa or dopamine agonists?

A

adjust dose in cases of QT prolongation to minimize risk of arrhythmias.
max dose = 30 mg/day

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19
Q

Which drugs should be avoided in patients with PD?

A

AVOID:
-metoclopramide (crosses BBB = EPS symptoms)
-1st and 2nd gen antipsychotics - worsens parkinsons symptoms bc it blocks dopamine Rs (but Quetiapine or Clozapine are ok)
-Valproic acid, Lithium - worsens tremors/motor symptoms. (phenytoin is OK)

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20
Q

orthostatic hypotension related to PD?

A

caused by anti-PD meds, other meds, or PD itself
-get a lying and standing BP at each dr visit

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21
Q

How to manage orthostatic hypotension?

A
  1. Reduce dose of levodopa or dopamine agonist
  2. Add salt to diet
  3. Add domperidone or fludrocortisone
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22
Q

When should domperidone be taken?

A

30 minutes prior to each dose (of anti-PD drugs) - max dose of 30 mg/day*******

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23
Q

side effects of domperidone ?

A

increased ventricular arrhythmias, sudden cardiac death.

USE THIS FOR SHORT DURATION!

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24
Q

How to manage psychosis, confusion, agitation, hallucinations, delusions?

A
  1. reduce dose of levodopa or dopamine agonist
  2. discontinue anticholinergic drugs, amantadine, selegiline
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25
What drugs can be used to treat psychosis in PD?
quetiapine or clozapine
26
Non-selective dopamine (D1 & D2) agonists
bromocriptine
27
Selective D2 agonists
pramipexole 0.5-1 mg TID ropinirole 3-6 mg TID rotigotine transdermal patches
28
Side effects of dopamina agonists
GI: N/V, constipation Ortho hypotxn Hallucinations, Psychosis Erythromelalgia (burning pain, warmth, redness of extremities) Sudden Sleep attacks Compulsive behaviors like GAMBLING, HYPERSEXUALITY Pleural fibrosis
29
Why must doctors do a base line chest X ray?
risk of pleural fibrosis if patient is prescribed dopamine agonists
30
Drug interactions with pramipexole ?
erythromycin (increases bioavailability by 200%)
31
what patient population should not take D2 agonists?
patients > 70 years old
32
What are the benefits of adding dopamine agonists to levodopa?
Can be used to extend the duration of exogenous levodopa dose (reduces wearing off effects), but will not delay motor complications like dyskinesia from levo.
33
Which class of drugs can cause sudden sleep attacks while driving?
Dopamine agonists
34
Why are non-ergot dopamine agonists more preferrable than ergot-derived dopamine agonists?
Non-ergots (prami, ropinirole) = better safety profile (but can still cause sleep attacks), but the ergots (bromocriptine) have the additional risk of fibrosis (scarring of tissues)
35
What is the benefit of switching Sinemet (levo/carb) --> Sinemet CR?
Dosing interval with CR is increased by 30-50% (i.e., from Q4hrs to Q6hrs), longer duration of the formulation -CR provides steadier dopamine levels = helps reduce motor fluctuations (wearing-off effect) -CR has a slower onset so may require a higher dose increased by 10-30%
36
dopamine precursors
levodopa/carbidopa
37
dosing of domperidone
10 MG with every dose of sinemet. avoid > 30 mg in patients with QT prolongation
38
drug interactions with levodopa
-anti-hypertensives -phenytoin -metoclopramide (eps) -vitamin b6 (increased N/V)
39
side effects of levodopa
mnemonic: LEVODOPA Lethargy Euphoria Vomiting Orthostatic hypo Delirium/delusion On-off effect Priapism Athetosis (dyskinesia)
40
true or false- levodopa is preferable to take on an empty stomach 1hr before or after meals?
true. but if n/v, can take with food to minimize
41
What is the role of amantadine?
drug of choice in drug-induced PD, to decrease dyskinesia caused by levodopa in later stages of disease
42
MoA amantadine
NMDA antagonist, may increase dopamine release and inhibit dopamine reuptake
43
Side effects of amantadine
hallucinations ankle or feet edema livedo reticularis (rose-colored mottling of skin in lower legs/feet, swelling)
44
Drug interactions with amantadine
-memantine (do not combine!!!) -possible toxicity due to drugs that impair renal function (ex. diuretics)
45
MAO-b selective inhibitors
selegiline rasegiline
46
side effects of MAO-b inhibitors
insomnia confusion hallucinations anorexia diarrhea increased dyskinesia
47
DDIs with MAOb inhibitors
drugs that can cause serotonin syndrome: SSRIs, TCas, MAOi, triptans, linzeolid, dextromethorphan COCs: reduce dose of selegiline Cipro or other 1A2 inhibitors (fluvoxamine)
48
Liver disease and MAOb inhibitors
-reduce dose if mild -if severe, don't use drug
49
True or false? Adding selegiline to levodopa increases mortality
TRUE
50
When is benztropine (an anticholinergic agent) indicated?
Drug-induced PD i.e., by antipsychotics. effective for tremors, but not rigidity or bradykinesia -use as monotherapy, or adjunct to dopamine drugs
51
Benztropine counselling points?
AEs: anticholinergic (constipation, blurred vision, dry mouth, urine retention) -with food, or milk to reduce GI effects
52
In what patient populations should benztropine be avoided?
patients > 70 y/o
53
COMT Inhibitors
Entacapone 200 mg (max upto 8 times per day)
54
Role of entacopone
given with levodopa, helps extend the duration of levo's effects by 1 hour (for wearing off effect) helps decrease dyskinesia requires special access program
55
Side effects of entacapone?
-dyskinesia diarrhea (weeks-to months of initiation) -nausea -hallucination -urine discoloration (Brown-orange color) -dopamine activity in the brain = dyskinesia, confusion, hallucination
56
what is dyskinesia?
involuntary movement = jerking, twisting
57
Wearing-off effect
also known as "end of dose" effect from long-term use of LEVODOPA. -Predictable, occurs at the later part of dosing interval. -effects of the dose diminish before next dose is due, so patients have a gradual return of PD symptoms -common in early stages of motor fluctuations
58
Management of wearing-off effect
1) Increase dosing frequency of levodopa. 2)Add adjunctive therapies like: COMT inhibitors (e.g., entacapone): Extend levodopa's half-life. MAO-B inhibitors (e.g., rasagiline, selegiline): Reduce dopamine breakdown. Dopamine agonists (e.g., pramipexole, ropinirole): Provide more continuous stimulation. 3)Use controlled-release levodopa to smooth out fluctuations.
59
Key diff between on-off effect and wearing off effect
O/F = unpredictable, unrelated to levo W/O = predictable, related to levo dosing time
60
On-Off effect
unpredictable, sudden fluctuation between period of mobility (ON period) and immobility/worsening of symptoms (OFF period), UNRELATED to timing of levodopa dose, so it can happen even during a dose's peak effectiveness.
61
how to manage on-off effect?
similar to wearing-off effect: 1. increase freq of levo 2. add DA, MAOi, or COMTi

Neuropsychiatry (12 decks)

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