Parkinson’s Disease Flashcards
Define PD. (2)
A progressive neurodegnerative condition due to death of dopamine.
2 types: PIGD, Tremor dominant PD.
What are the causes of PD? (5)
Secondary Parkinsonism:
- Drugs = Induce Parkinsonism Syndrome
- Toxins = MPTP
Vascular Parkinsonism:
- Cerebral infarction
Parkison’s Plus Syndrome:
- Multiple System Atrophy
- Progressive supra-nuclear palsy
- Lewy Body Dementia
Give e.g. of drug that causes parkinsonian syndrome. (8)
Neuroleptics
Anti-psychotics (e.g. Haloperidol, Chlorpromazine)
Anti-depressants
Anti-emetics (e.g. Metoclopramide, Prochlorperazine)
Cinnarizine
CCB
Lithium
Donepezil
What are the cardinal features/motor symptoms of PD? (3)
Tremor (rest, ‘pill-rolling’, 7/10 px only)
Rigidity (increased tone - stopping posture, ‘cog wheeling’)
Hypokinesia (akinesia, bradykinesia, slowness of movement)
What are the autonomic dysfunction s/e of PD? (9)
Constipation
Excess sweating
Saliva pooling/drool
Dysphagia
Weight loss
Urinary dysfunction
Aphasia and speech/volume changes
Postural instability/hypotension
Speeding issues
What other s/e indicate PD? (10)
Mask like face
Shuffling gait
Flexed postures of neck, trunk and limbs.
Cognitive decline
Dementia (8/10)
Anxiety
Pain/Dystonia
Restless Leg Syndrome
Depression
REM sleep disorder (common but not all px)
How is PD diagnosed? (1)
Mainly upon clinical presentation.
Review diagnosis on 6-12 monthly basis in case of an inaccurate diagnosis.
What are the tx aims of PD? (1)
Improve symptom control
What drugs are used as PD tx? (6)
Levodopa
Dopamine agonists
MAO-B inhibitors
Amantandine
COMT inhibitors
Anticholinergics (rarely used)
State the main features of levodopa.
Used in all stages of PD.
Give with a dopa-decarboxylase inhibitor (Benserazide/Carbidopa):
- Reduces peripheral conversion of Levodopa to dopamine.
- Limits s/e.
S/E:
- Impulse Control Disorder
- N+V
- Taste disturbances
- Dry Mouth
- Postural Hypotension
- Drowsiness
- Fatigue
- Confusion
- Psychosis
- Dystonia
- Dyskinesia
Keep to 800mg or less where possible, < 2g daily.
Start with low dose and increase gradually.
Keep dose as low as possible to maintain good function in order to reduce development of motor complications.
Usually commenced BD or TDS.
Caution:
- Severe pulmonary and CVD
- Psychiatric illness
- Dyskinesia
Preparation:
- Madopar (Co-beneldopa)
- Capsules (62.5mg, 125mg, 250mg)
- Dispersible tablets (62.5mg, 125mg)
- MR capsules (125mg)
- Sinemet (co-careldopa):
- Tablets (62.5mg, 100mg, 125mg, 275mg)
- MR tablets (Half Sinemet CR 125mg, Sinemet CR 250mg)
Counselling Points:
- May discolour the urine
- Take with or just after food or meal.
- Driving: Care can cause sudden onset of sleep and hypotensive reactions.
- Explain differences in names.
- MR: Swallow whole; don’t take indigestion remedies 2 hrs before or after.
- Dispersible: Can be dispersed in water or orange or swallow whole. Will always leave a white residue.
Switching from MR levodopa to dispersible co-beneldopa = reduce by 30%.
When switching from IR to MR, initially 1 capsule per 100mg levodopa. Titration can take up to 4 weeks usually require increase 50% of previous levodopa dose.
When used as an adjunct to other antiparkinsonian drugs, once therapeutic effect is apparent, the drug may be reduced or withdrawn.
State the main features of Dopamine Agonists.
Direct action on dopamine receptors.
Can be used as monotherapy in early stages of PD and with levodopa in advanced PD.
Low doses and titrate.
Ergot-derived: bromocriptine, pergolide, cabergoline. (Not first line, rarely used, Fibrotic reactions, exclude cardiac valvuopathy)
Non-ergot derived: Apomorphine (pump delivered), Pramipexole, Rpinorole, Rotigotine. (Caution: Psychiatric disorders, regular eyes tests, CVD.)
S/E: Psychiatric, Impulse control disorders, sudden onset of sleep, hypotensive reactions, N+V, Constipation, Dyspepsia, Hallucinations/Delusions/Confusion, Common in younger men particularly those on levodopa.
Counselling: Impulse control disorders, driving, take with or just after food or meal. Cabergoline (dispense in original container), Patch (apply to dry, non-irritated skin on torso, thigh or upper arm removing after 24 hrs. Put on replacement patch on a different area, don’t cut.) When used with levodopa, levodopa dose = reduced.
State the main features of Rotigotine patch.
Monotherapy 2mg/24 hr patch
Adjunct 4mg/24 hr patch
If switching from levodopa or dopamine agonist, need conversion. Consider s/e e.g. hallucinations and ensuring PD symptoms are adequately controlled.
State the main features of MAO-B inhibitors.
Cautions: Selegiline: Gastric/duodenal ulcers, uncontrolled hypertension, s/e of levodopa can be increased.
S/E: Nausea, Constipation, Dry Mouth, Selegiline: Mouth ulcers, hypertension, bradycardia, psychosis, impaired balance, sedation.
Rasagiline: Headache, Dizziness
Counselling: Avoid food with too much tyramine as raised BP e.g. aged cheese, sour cream, yoghurt, dry meals.
Selegine dispersible: place on the tongue and low to dissolve. Don’t drink, rinse mouth out 5 minutes after taking.
State the main features of COMT inhibitors.
Catechol-O-methyltransferase inhibitors: Entacapone, Tolcapone, Opicapone.
- Prevents peripheral breakdown of levodopa by inhibiting COMT.
- Adjunct agents to co-beneldopa and co-careldopa for px with end dose deterioration.
Entacapone:
- Caution: IHD, levodopa dose need to be reduced.
- Avoid in hepatic impairment.
- S/E: N+V, Abdominal pain, Constipation, Urine (reddish/brown)
- Found in product containing levodopa, Stalevo: (Carbidopa, Levodopa, Entacapone)
Counselling: Alter urine colour, driving, avoid iron containing products at the same time of day. Diarrhoea when starting and few months later.
Tolcapone: specialist initiation
- Caution: Hepatotoxicity
- S/E: Constipation, Dyspepsia, N+V.
- Counselling: signs of liver disorders and seek medical attention if they develop N+V, fatigue, abdominal pain, dark urine or pruritis. Attend regular blood monitoring.
Opicapone:
- Caution: Hepatic impairment, concurrent levodopa dose, elderly > 85 yrs.
- S/E: Constipation, Dizziness, Drowsiness, Dry Mouth, Hypotension, Movement disorders.
- Counselling: Take at bedtime, at least 1 hr before or after levodopa combination
State the main features of Amantadine.
Glutamate antagonist.
Used with other agents.
Rarely used due to dyskinesia (LT use)
Useful for fatigue.
Caution: CHF
C/I: Epilepsy, Gastric Ulceration
S/E: GI disturbances, Anorexia, Dry Mouth, Confusion, Hallucinations.
State the main features of Anticholinergics.
No first choice due to neuropsychiatric s/e.
E.g. Procyclidine, Orphenadrine Hydrochloride, Trihexyphenidyl Hydrochloride.
Useful in reducing symptoms caused by antipsychotic drugs.
Caution: CVD, HPT and Psychiatric disorders.
S/E: Confusion, Dry Mouth, Constipation, Blurred Vision
Counselling: Driving
What counselling is given for PD?
Take medications on time.
Avoid abrupt withdrawal (NMS risk - altered consciousness, fever, autonomic instability, raised CK levels, Check CK levels if abrupt withdrawal)
Impulse Control Disorders: (Occurs with all dopaminergic therapy, can occur at any stage of disease, discussion recorded, contact is given, px can conceal behaviour. Different types: gambling , hyper sexuality, binge eating and obsessive shopping.)
Food: Take medicine with cold water or squash NOT milk. Protein can interfere with effects of levodopa. If this occurs, levodopa 30 mins before meals, ideally with a carbonhydrate food .e.g cracker or biscuit.
Excessive sleepiness and sudden onset of sleep: Inform px not to drive if they suffer form this/operate heavy machinery, Inform DVLA of symptoms.
What are the guidelines associated with early PD? (2)
Early stage of PD where motor symptoms impact QOL: Levodopa
If motor symptoms don’t impact QOL: Levodopa, Dopamine agonists, MAO-B inhibitors.
What are the guidelines associated with adjuvant therapy for motor symptoms? (3)
Dopamine agonists
COMT inhibitors
MAO-B inhibitors
What therapies are being developed for PD? (3)
Aid motor symptoms: Scored tablet, Dhivy (Carbidopa/levodopa)
Adjuvant therapy to Carbidopa/levodopa: Aid off periods (Safinamide, levodopa inhalation powder, Istradefylline, Sublingual apomorphine, Opicapone)
Dyskinesias: Amantidine ER
State the management process of postural hypotension.
Review existing medications
Consider midodrine/ fludrocortisone (if midodrine is ineffective/not tolerated)
State the management process of hallucinations.
Review cause, treat cause, review PD medication (reduce dose)
Consider quentiapine if there’s no cognitive impairment.
Clozapine if standard tx fails
Don’t treat if well tolerated by px/family/carers.
State the management process of constipation.
Increase dietary fibre and fluid intake and exercise levels.
Consider laxatives.
State the management process of N+V.
Mild: related to levodopa or dopamine agonists therapy.
Severe/persistent: low dose Domperidone for shortest time. (CVD = Domperidone) Review PD medication.
State the management process of daytime sleepiness.
Modafinil
Explain how a pharmacist can contribute to PD care.
Dysphagia:
Can px swallow/ NBM/ NG tube insertion? Px alert?, Who is administering/looking after administration of px medication?, seen/referred to SALT?
Options: Madopar switched to dispersible tablets (swallowing issues)
Switch Sinemet to Madopar dispersible
Madopar MR capsules to dispersible tablets
Pramipexole - dispersible in water (MR switch to IR tablets and give TDS)
Rotigotine patch (best option for LT)
Alternative therapies: Co-enzyme 10, Vitamin E)
Lifestyle advice: Exercise, Diet
NICE: POC, ICD, physiotherapist/OT referral and SALT, levodopa in hospitals or care homes, Access to Clozapine for treating hallucinations and delusions.
Taking complex Hx: Correct dose name, form, brand, dose and timings. X interchanging medications without PDNS/PD specialist.
Reviewing medication chart: correct form and timings. If PD medications are taken 15 mins late this can cause px harm. No interactions.
Providing info: Taking medication, s/e, adherence/compliance issues, counselling, signposting and lifestyle advice.
