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IPAP 21-2 Soph Semester > Parkinson’s Drugs For Block III > Flashcards

Parkinson’s Drugs For Block III Flashcards

1
Q

What is the pathophys of Parkinson’s

A

caused by an imbalance between dopamine (DA) and acetylcholine (ACh) neurons on innervation of gamma-aminobutyric acid (GABA) receptors

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2
Q

What are the S/s of PArkinsons

A

Tremor, Rigidity, Dyskenesia, Akenesia, Bradykinesia, Postural/ Gait Disturbance

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3
Q

Clinical presentation Parkinson’s?

A

Flat affect, reduced blinking, flat face, Depression, Dementia, Psychosis

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4
Q

Which drugs can induce Parkinson’s like S/s

A

Antipsychotics (i.e. phenothiazines) and Antiemetics

Prochloroperazine (Compazine) (Antiemetic)

Chlorpromazine (Thorazine) (antiemetic)

Trifluoperazine (Stelazine) (1* typical)

Thioridazine (Mellaril) (1* typical)

Haloperidol (Haldol) (1* typical)

Metoclopramide (Reglan) (GI Benzamide)

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5
Q

Which Dopamine agent is best at Tx improving motor disability

A

Levodopa

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6
Q

Which Dopamine Agent is best at Lessing Motor complications

A

Dopamine agonists

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7
Q

What are the 1st line monotherapy Tx for Parkinson’s

A

Dopamine agonists

Bromocriptine (Parlodel)

  • Semisynthetic ergot derivate
  • Rarely used

Rotigotine (Neupro)

  • Non-Ergot
  • Transdermal system
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8
Q

What are the ADE of Dopamine Agonists Bromocriptine and Rotigotine

A

Pleuropulmonary and/or cardiac fibrosis is a concern
-Chest x-ray with abnormal pulmonary exam

Postural hypotension, dizziness

Hallucinations, mental confusion

GI disturbances

Digital vasospasm and leg cramps

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9
Q

What Parkinson’s Drugs are used for RLS

A

Pramipexole (Mirapex)
Ropinirole (Requip)

(NONERGOT)

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10
Q

What is the clinical use of Pramipexole

A

Effective as monotherapy for mild parkinsonism and in patients with advanced disease

Allows the dose of levodopa to be reduced and smoothing out response fluctuations in advance disease.

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11
Q

What is the clincal use of Ropinirole

A

Affective as monotherapy in patients with mild disease

Allows the dose of levodopa to be reduced and smoothing out response fluctuations in advance disease

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12
Q

Parkinson’s pts with advanced disease should get:

With mild disease should get?

A

Advanced: Pramipexole
Mild: Ropinirole

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13
Q

What is the clinical use of Apomorphine

A

acute, intermittent treatment of “off” episodes associated with advanced Parkinson disease;

recurring hypomotility, “off” episodes

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14
Q

What is the MOA of Apopmorphine

A

Dopamine receptor agonist (Short-acting)

Stimulates post-synaptic D2-type receptors

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15
Q

How must apomorphine be titrated

A

Must be titrated in a setting where BP can be monitored

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16
Q

What should be done if a pt misses a Apomprphine does x 1 wk

A

If patient does not dose for more than 1 week, reinitiate at 0.2ml dose and increase

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17
Q

What are the ADE of apomorphine

A

Severe N/V

Ortho hypotension
Hallucinations
Dyskinesia
Somnolence

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18
Q

What is the prophylaxis Tx for N/V with apomorphine

A

prophylaxis with trimethobenzamide (anti-emetic) 3 days prior to initiating apomorphine and continued for the first month of therapy, if not indefinitely

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19
Q

What are the contraindications of Apomorphine

A

5-hydroxytryptamine-3 antagonists (5-HT3) antagonists (ondansetron, granesitron, dolasetron, palonosetron) causes severe hypotension and loss of consciousness

IV use (thrombus formation)

Sulfite sensitivity (preservative)

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20
Q

How must apomorphine be admin

A

Sub Q!

IV use= thrombus formation

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21
Q

What drugs should apomorphine be avoided in

A

5-hydroxytryptamine-3 antagonists (5-HT3) antagonists (ondansetron, granesitron, dolasetron, palonosetron)

causes severe hypotension and loss of consciousness

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22
Q

What is the MOA of carbidopa

A

Aromatic L-Amino Acid decarboxylase (AAAD) inhibitor that does not cross the BBB

Prevents some peripheral conversion and metabolism of levodopa to dopamine in the peripheral tissues thereby allowing increased availability of levodopa to cross into the CNS

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23
Q

What is the MOA of Levodopa

A

Precursor to dopamine that has the ability to cross the BBB
and replenish depleted dopamine in the brain

Converted into dopamine in the periphery

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24
Q

How long does levodopa have effect till it begins to decline

A

“Honeymoon”: patients normally respond favorably to levodopa for 3-5 years then the effects start to decline

25
Q

What are the ADE of Carbidopa and Levodopa

A

Acute Effects (excessive dopamine): nausea, vomiting, postural hypotension, confusion, agitation, hallucinations, cardiac arrhythmias

Dyskinesias (excessive dopamine):
Drug induced abnormal involuntary movements, including dystonia

Treatment: decrease levodopa dose or add an anticholinergic or amantadine as an anti-dyskinetic drug

26
Q

What is the Tx for dyskinesia induced by levodopa

A

Treatment: decrease levodopa dose or add an anticholinergic or amantadine as an anti-dyskinetic drug

27
Q

What is the role of amantadine

A

Anti-dyskinesia medication

28
Q

How do we treat the “wearing off” period of Levodopa

A

“Wearing Off” phenomenon: end of dose deterioration, symptoms return before the next dose

Treatment: add dopamine agonist, adding a MAO-B inhibitor, a COMT inhibitor or increasing the frequency dose of levodopa (shorten the dosing interval)

29
Q

How do we treat the “on- OFF” phenomenon of Levodopa

A

unpredictable return of symptoms without respect to the dosing interval

Severity changes ranging from akinesia (off periods) to mobility with dyskinesias (on periods)

Treatment: add dopamine agonist, adding a MAO-B inhibitor, a COMT inhibitor or redistributing dietary protein (high-protein diet reduces levodopa absorption; must keep steady intake)

30
Q

What effect does a high protein diet have on Levodopa

A

Reduces absorption

31
Q

What pts should not receive L-dopa

A

Contraindications:

  • psychotic illness
  • narrow-angle glaucoma
  • use of non-selective MAOI’s

Precautions:
Peptic Ulcer Disease (PUD)
Malignant Melanomas: levodopa is a precursor of skin melanin and conceivably may activate malignant melanoma

32
Q

What is the association of L-Dopa and skin cancer

A

levodopa is a precursor of skin melanin and conceivably may activate malignant melanoma

33
Q

What is the clinical use of MAO-B inhibitors

A

Symptomatic control of (mild to moderate) Parkinson Disease

Adjunct therapy for patients with Parkinson’s Disease and motor fluctuations

34
Q

Pts on Selegiline and Rasagiline should avoid what medications

A

Patients on MAO-B Inhibitors should avoid medications that increase the risk of Serotonin Syndrome

35
Q

What is the MOA of selegiline

A

Irreversibly inhibits the metabolism of dopamine by MAO-B that results in increased dopamine levels in the brain

36
Q

Does Selegiline effect MAO-A ?

A

Does not inhibit MAO-A
(degrades: norepinephrine and serotonin)

much lower risk for hypertensive crisis

Loses selectivity at doses > 10mg/day

37
Q

When should the last dose of selegiline be taken to avoid insomina

A

Last dose should be early afternoon to prevent insomnia

38
Q

What is the clinical use for Selegiline

A

Used in conjunction with levodopa

Mild Disease: may be used alone to try and delay the need for levodopa in early Parkinson’s disease (effects have not been robust)

39
Q

What drug can be used as monotherapy in order to delay the use of L-dopa

A

Selegiline

40
Q

What is Selegiline metabolized to

A

Amphetamine, can cause insomnia

41
Q

What is the MOA of Rasagiline

A

MOA-B non selective inhibitor

42
Q

Which is more potent, Selegiline or Rasagiline

A

Rasagiline 5x more potent

43
Q

Because Selegiline and Rasagiline are MAO-b inhibitors what foods should be avoided

A

avoid tyramine containing foods

ex; aged cheeses, air-dried or cured meats, tap/draft beers, etc

44
Q

What is the MOA of a COMT inhibitor

A

prevents the breakdown of dopamine,

more levodopa available to cross blood-brain barrier

45
Q

What is the clincal indications for COMT-I

A

Manage motor fluctuations (“wearing-off” effect)

Adjunct to levodopa/carbidopa in patients with response fluctuations or who have failed or can not use other therapies

46
Q

What is the urine ADE of COMT-I

A

Entacapone causes orange discolored urine

47
Q

Since COMT-I increase the concentration of dopamine, what are the ADE

A

Increase Dopamine: diarrhea, dyskinesias, nausea, anorexia and hallucinations

48
Q

When should tolcapone (MAO-I) be used

A

After Entacapone has failed

Hepatotoxic: get liver function tests (LFTs) at baseline and on a regular basis
Written informed consent is advised by manufacturer for patients who have failed Entacapone

49
Q

What is the major ADE of tolcapone

A

Liver toxicity

50
Q

How should Entacapone be used (MAO-I)

A

Must use with carbidopa/levodopa

Does not cross BBB

51
Q

What is the combination of Carbidopa/l-dopa/Entacapone called

A

Stalevo

52
Q

How are anticholinergics used in the Tx of Parkinson’s

A

Mechanism of Action: block the excitatory neurotransmitter acetylcholine to try and restore balance with dopamine

Clinical Use:

  • Most effective on tremors and rigidity
  • DOC for drug-induced (anti-psychotics) parkinsonism
  • Does not relieve symptoms of tardive dyskinesia
53
Q

Since Benzotropine and Trihexyphenidyl are anticholinergics, what are their ADE

A

dry mouth, blurred vision, dry eyes, constipation, urinary retention, confusion, and arrhythmias

54
Q

What are the DOC for drug induced Parkinson’s

A

Benzotropine or Trihexyphenidyl

55
Q

What is the clincal use of Amantadine

A

Posses symptomatic benefits and may reduce dyskinesias caused by levodopa or dopamine agonists

Not as effective on bradykinesia, rigidity, tremor and dyskinesia as anticholinergics

56
Q

What is the major ADE of Amantadine

A

Livedo reticularis (RASH)

57
Q

How do you tx parkinson drug induced hallucination

A 
Stop medications that may contribute to psychosis in the following order: 
-anticholinergics, 
-amantadine, 
-selegiline, 
-dopamine agonists, 
levodopa/carbidopa

Avoid typical antipsychotics, risperidone, and olanzapine; worsens Parkinson symptoms

58
Q

How do you Tx the cognitive disorders of drug induced Parkinson’s

A

Discontinue/reduce Parkinson disease medications as tolerated

If antipsychotics are needed treat with newer neuroleptics:

Quetiapine (Seroquel)
Clozapine (Clozaril): probably best but unacceptable side effects (agranulocytosis)

IPAP 21-2 Soph Semester (20 decks)

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