Parkinson's Disease

Question 1

What are the symptoms of PD?

TRAMPP

Answer 1

Tremor - Resting tremore
Rigidity - cogwheel
Akinesia / bradykinesia
Mask face
Pill rolling
Postural instability

Question 2

3 medications that can cause psuedoparkinsons

Answer 2

Haldol
Reglan
Prochlorperazine

Because these are DA antagonists

Question 3

What is end of dose effect and how to fix it

Answer 3

Wearing off occurs 3-5 years after being on levodopa and causes the drug to have shorter duration of action

Decrease interval, add DA agonist, add COMT inhibtior or MAOi

Question 4

What is dyskinesia and what do you do?

Answer 4

Too much dopamine

Decrease levodopa dose, add DA agonist/amantadine

Question 5

What three anticholinergics can we use for PD?

Brand name
ROA

When not to use

Answer 5

Diphenhydramine - bendaryl - PO/IM/IV

Trihexyphenidyl - artane - PO

Benztropine - cogentin - PO/IV/IM

BPH , galucoma , bladder neck obstruction, myasthenia gravis

Question 6

Carbidopa/levodopa

Brand
Formulation
Minimum dose
Transition from CR to non-CR
Food interactions

Answer 6

Sinemet

Tablets, ODT, Suspension

Need minimum 75mg of carbidopa per day (so 25/100 TID is typical starting dose)

Must increase dose if going from CR to non-CR because CR is less bioavailable

High protein diets

Question 7

Selegiline

Brand/formulation
Class
Counseling
Drug interactions

Answer 7

Eldepryl - PO
Zelapar - ODT
Ensame - Patch (MDD)

MAOI-B

Do not take second dose past 2 pm because it has amphetamine

If >10mg - don’t give with SSRI
Contraindicated with Meperidine
Methadone, tramadol, flexiril, dextromethorphan, st.john’s wort

Question 8

Rasagiline

Brand /ROA
Class
Food interaction

Answer 8

Azilect - PO

MAOI-B

Tyramine-rich foods like aged cheese (risk of HTN crisis)

Question 9

Safinamide

Brand / ROA
Class

Answer 9

Xagdago - PO

MAOI-B

Question 10

Amantadine

Brand
MOA

Answer 10

Symmetrel

NMDAR antagonist, increase DA release presynaptically, anticholinergic effect

Question 11

Bromocriptine

Brand
Class
Indications
ADE

Answer 11

Parlodel , cycloset

DA agonist

PD, hyperprolactinemia, acromegaly, T2DM (cycloset)

N/V, hallucinations, OH

Question 12

Pramipexole

Brand
Class
Indication
ADE

Answer 12

Mirapex

DA agonist

PD, RLS

Somnolence (sleep attacks)

Question 13

Rotigotine

Brand
Class
Indication
Frequency

Answer 13

Neupro patch

DA agonist

PD, RLS

DAILY patch

Question 14

Ropinirole

Brand
Class
Indication
Caution

Answer 14

Requip

DA agonist

PD, RLS

Caution in liver dysfunction

Question 15

Apomorphine

Brand
Class
ROA
When to use
Premedicate

Answer 15

Apokyn
Kynmobi - SUBLINGUAL

DA agonist

SUBQ

Only use as needed to treat sudden wearing off episodes

Must start 3 days before - give trimethobenazmide (tigan) , NEVER give 5HT3I (severe hypotension)

Question 16

When to use DA agonists

Answer 16

Typically first , especially in younger patients with PD to prevent wearing off effect with sinemet

Question 17

When to use COMTi

Answer 17

In addition to sinemet

Question 18

Entacapone

Brand
Class
ADE

Answer 18

Comtan

COMT I

Brownish orange urine discoloration

Question 19

Tolcapone

Brand
Class
BBW

Answer 19

Tasmar

COMT I

Hepatotoxicity

Question 20

Stalevo components

Answer 20

Carbidopa + levodopa + entacapone

Question 20

Opicapone

Brand
Class
Dose

Answer 20

Ongentyz

COMT I

QD HS empty stomach

Question 21

Pimavanserin

Brand
Indication
MOA

Answer 21

Nuplazid

Hallucinations and delusions associated with PD psychosis

5HTR antagonist

Question 22

Inhaled levodopa

Brand
MOA
Indication
Dose
Contraindication

Answer 22

Inbrija

DA precuroser

For off episodes up to 5x/day

Inhale 2 capsules as needed

14 days within MAOI

Question 23

Istradefylline

Brand
MOA
Indication
Dose

Answer 23

Nourianz

Block adenosine receptor - similar to caffeine and theophylline

add on therapy to treat off periods while on sinemet

20-40mg QD