parkinson's disease in practice Flashcards by Sarah Ramsbottom

What is PD?

chronic, progressive, neurodegenerative condition

loss of DA cells in the substantia nigra

bradykinesia with one of: rigidity, tremor, postural instabiility

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motor complications of PD

deteriorating fxn
loss of drug effect
motor fluctuations
dyskinesia
freezing of gait
falls

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non-motor complications of PD

mental health conditions
autonomic dysfunction
other complications

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mental health conditions associated with PD

depression
anxiety
dementia
cognitive impairment
impulse control disorders
psychotic symptoms

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autonomic dysfunction associated with PD

constipation
orthostatic hypotension
dysphagia
weight loss
excessive salavation
excesive sweating
bladder problems
sexual problems

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other complications associated with PD

n&v
pain
sleep disturbances
daytime sleepiness
aspiration pneumonia
pressure sores

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What is neuroleptic malignant syndrome (NMS)?

rare, life-threatening idiosyncratic reaction

occours if DA drugs stopped abruptly

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symptoms of neuroleptic malignant syndrome

fever
altered mental state
muscle rigidity
raised creatinine kinase
autonomic dysfunction

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management of NMS

IV fluids
correct metabolic abnormalities
cooling blankets
IV dantrolene
restart PD meds

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Why give IV dantrolene for NMS?

it acts on skeletal muscle
interferes with Ca influx
stops muscle contraction and muscle rigidity
reduces hyperthermia

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When is levodopa given?

first line in early PD stage

when motor symptoms impact QoL

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MOA of levodopa

converted/decarboxylated to DA in brain

DA acts on DA receptors

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formulations of levodopa

can be formulated with benserazide (co-beneldopa) or carbidopa (co-careldopa)

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Why combine levodopa with benserazide/caridopa?

they are DOPA-decarboxylate inhibitors
inhibit peripheral decarboxylation of levodopa before it crosses BBB
inc the amount of DA that reaches the brain

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disadvantages with levodopa

becomes less effective over time
can get ‘wearing off’
LT use can result in dyskinesia
WD symptoms

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s/e with levodopa

N&V
hypotension
reduced apetite
hallucinations
sleep disturbances

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How to take levodopa?

absorption reduced with iron, take separately
absorption reduced with protein, separate
take 30-60mins before meal
N&V on empty stomach, can take with low protein snack like crackers
could eat most of your protein in evening to improve daytime symptoms

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2 brands of combined levodopa

Madopar - co-beneldopa

Sinemet - co-careldopa

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When are DA agonists used?

early stages of PD in patients whose motor symptoms don’t impact on QoL

can use in combination with levodopa when get wearing off symptoms/fluctuations

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MOA of DA agonists

act directly on DA receptors to mimic effects of DA

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2 classes of DA agonists

ergot derived

2. non-ergot derived

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examples of non-ergot derived DA agonists (these onse are used, not ergot anymore)

pramipexole
ropinirole
rotigotine
apomorphine

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s/e with DA agonists

nausea
constipation
hypotension
headaches
anxiety
depression
movement problems

problems with DA agonists

fainting/dizziness
sudden onset of sleep
impulsive/compulsive behaviours
hallucinations/dellusions
withdrawal

caution when dispensing pramipexole

dose/strength in terms of pramipexole base but can be in salt form

ropinirole and smoking

might need dose adjustments if stopping/starting smoking during Tx

What happens if missed one day's dose of ropinirole?

might need dose titration

rotigotine form and advantage

24hr patch useful if swallowing difficulties

problems with rotigotine patch

skin irriation - different site every day contains aluminium - take off for MRI scam or cardioversion

apomorphine form

SC via disposable pen/cartridge/infusion pump

When is apomorphine useful?

continuous infusion to reduce 'off' periods injections can be used as rescue Tx works in 5-10mins

problems with apomorphine

causes N&V highly emetic give domperidone 2 days before start of Tx

When are MAO-B inhibitors used?

patients in early PD whose motor symptoms don't impact QoL

MOA of MAO-B inhibitors

inhibit breakdown of DA by MAO-B

examples of MAO-B inhibitors

selegiline rasagiline safinamide

problems with MAO-B inhibitors

interact with antidepressants worsen s/e of levodopa - dyskinesia impulsive/compulsive disorders withdrawal risk of hypertension when taken with tyramine rich foods

s/e of MAO-B inhibitors

``` headaches constipation dry mouth aching joints indigestion urinary urgency ```

selegiline oral lyophilizate

if swallowing difficulties tablet on tongue and disperses in 10 seconds can't drink/eat/rinse mouth 5 mins after taking

When are COMT inhibitors used?

with levodopa for patients who have developed dyskinesia or motor fluctuations on levodopa to reduce 'off' periods improve motor symptoms and daily activities

MOA of COMT inhibitors

inhibit peripheral methylation of levodopa to 3-O-methyldopa allow more levodopa to reach the brain

Are COMT inhibitors used alone?

NO in combination with levodopa -> reduce levodopa dose by 10-30% whan stating COMT inhibitor

examples of COMT inhibitors

entacapone opicapone tolcapone

problems with COMT inhibitors

``` colour urine bright red/orange diarrhoea risk of fatal liver damage - tolcapone worsen s/e of levodopa - dyskinesia, N&V impulsive/compulsive behaviours ```

s/e of COMT inhibitors

``` confusion diziness falls dry mouth hallucinations sleep disorders chest pain fatigue ```

How to take entacapone?

take at same time as levodopa don't take at same time as IRON supplements - reduced absorption

combination product of levodopa and entacapone

co-careldopa + entacapone = Stalevo

How to take opicapone

at bed time 1hr before/after levodopa

When is amantadine used?

adjunct if dyskinesia not managed

What type of drug is amantadine?

glutamate antagonist

importance of PD meds on time

can impact patinet's health - reduced movement - unable to get out of bed - unable to swallow - unable to talk - unable to walk delay of 30mins can have bad effects

accurate drug Hx for PD

med name formulation exact timing

if PD patient is nil my mouth

need to convert crirital oral meds to non-oral route and calculate equivalent doses - via NG tube - topical pach

What PD drugs can be left out in acute nil my mouth situation?

amantadine selegiline rasagiline

What to convert levodopa to if NG not available?

equivalent rotigotine patch

max dose of rotigotine patch

16mg

What can happen if patient is DA agonist naive and converting their levodopa to rotigotine patch in acute situation?

specialist review required risk of s/e - voiting - skin rxns - hallucinations - inc confusion start at lower dose (2-4mg) and inc gradually over a few days

meds to avoid in PD

``` metoclopramide prochlorperazine (Stemetil) haloperidol chlorpromazine St John's Wort decongestants - phenylephrine anticholinergics ```