Parkinson's tx Flashcards
PD disease progression
-over 5-10 years w inc in motor sx
-cognitive sx after several years
-~15 year life expectancy after dx
PD clinical presentation
-tremor
-bradykinesia
-rigidit
-gait
-anxiety/depression
-constipation
-dementia
-insomnia
-hypotension
-psychosis/delirium
-sexual dysfunction
Goals of PD therapy
- minimize sx
- QOL
- ADLs
- minimize se
Non-pharmacologic tx of PD
-exercise/PT
-nutrition
-occupationaly therapy
-psych and speech therapy
PD tx
- rule out drug-induced
- Dopamine precursor
- DA agonist
- MAO-B inhibitor
- COMT inhibitor
- Amantadine
First line tx of PD
-rule out drug-induced
-dopamine precursor
-dopamine agonists
-MAO-B inhibitor
2nd line tx of PD
-COMT inhibitors
-Amantadine
Treatment initiation
-Levodopa for most
-can use dopamine agonist if <60 and higher risk for dyskinesia (risk of dyskinesia inc w time)
-IR > CR
-start low
-LDOPA > DA > MAOB for motor sx
AVOID DA agonists if
->70
-hx of ICD
-cognitive impairment
-xs daytime sleepiness
-hallucinationa
PD meds w better efficacy for motor sx
-LDOPA > DA > MAO-B
LDOPA
-gold standard
-N/V
-LD motor fluctuations/dyskinesia
-hallucinations
LDOPA clinical (or duodenal gel)
-inc absorption w empty stomach
-food dec nausea
-25/100mg PO BID-TID wf to start
-can inc freq as needed (5-6x day!)
-titrate to weigh risk v benefit
Patterns of motor fluctuations in PD
-duration of LDOPA concentration shortens w progression of disease
-doses go over threshold = dyskinesia
LD motor fluctuations
-wearing off: sx before next dose
-freezing (inability to move bc DA levels)
-delayed onset (benefits delayed)
-peak-dose dyskinesias (involuntary movements bc dose too high)
Dopamine agonist drugs
-Non-ergot
-Pramipexole (Mirapex®)
-Ropinirole (Requip®)
-Rotigotine (Neupro®)
-Apomorphine (Apokyn®
injection and SL film)
-Ergot (rarely use bc toxicity)
-Bromocriptine
(Parlodel®)
-Cabergoline (Dostinex®)
non-ergot Dopamine agonist clinical
-first line for initial tx
-minimize LD motor fluctuations
-long-acting formulations
-N/V
-suddeen onset sleep
-hallucinations
-impulse control disorder (ICD)
-Edema
-orthostatic hypotension
MAO-B inhibitors
-first line mild sx
-second line for adj
-motor and depression management
MAO-B inhibitors side effects
-N/V
-HA
-insomnia (selegiline)
-Hypo/Hyper tension
-avoid tyramine rich foods
-risk of serotonin syndrome (sertonergic antidepressants, dextromethorphan, serotonergic opioids)
MAO-B clinical
-once/twice daily dosing
-avoid tyramine-rich foods
COMT inhibitor side effects
-N/V
-brown/orange urine!! (entacapone)
-hepatotoxicity (toclcapone use limiting side effect)
COMT clinical
-prob no benefit in early stage PD
Anticholinergic drugs
-benztropine
-trihexyphenidyl
anticholinergic side effects
-confusion
-blurry vision
-urinary retention
-dry mouth
-constipation
-AVOID if >65 yo
Amatadine use
-manage LD motor fluctuations
-rarely monotherapy
-reserved for CD/LD peak dose dyskinesias
Amatadine side effects
-insomnia
-confusion
-hallucination
-livedo reticularis
-use is limited bc SE
Medications that can worsen PD:
Dopamine antagonists: antipsychotics, metoclopramide,
prochlorperazine, promethazine
Pros of dopamine agonists
-once daily dosing
-better tolerated by young pt
-limited motor fluctuations
Dopamine agonist cons
-$$
-less sx benefit than CD/LD
-many adverse effects
Who is treated w dopamine agonists
-age < 60 and higher risk of dyskinesia
-avoid in >70, ICD hx, cognitive impairment, drowsiness, hallucinations
MAO-B pros
-well tolerated
-delays onset of motor fluctuations
MAO-B cons
-least effective 1st line agent against motor sx
-dietary restrictions = risk of serotonin syndrome
MAO-B for who
-minor sx
-higher risk of motor fluctuations
Wearing off tx
-inc CD/LC dose or frew
-add DA, MAO, COMT
-XR CD/LD
freezing tx
-inc CD/LD dose/freq
-add DA agonist (apomorphine)
-add ODT CD/LD
delayed onset tx
-take CD/LD on empty stomach
-ODT CD/LD
-avoid CR/XR CD/LD
Peak-dose dyskinesia tx
-add amantadine
-dec dose of DA or CD/LD
Deep brain stimulation
-surgical tx if motor fluctuations not managed
-risk infection
-neurotransmtter on clavivle
Constipation in PD tx
-eval drug-induced
-inc fluids and activity
-laxatives
Insomnia in PD tx
-melatonin
-AVOID benzos (-pams)
Orthostatic hypotension in PD tx
-midodrine, droxidopa
-med equipment
Anxiety/depression tx in PD
-CBT
-SSRI
-SNRI
-AVOID benzo
-caution tricyclic antidepressants
Dementia in PD tx
-cholinesterase inhibitor
-AVOID: anticholinergics, benzos, antihistamines, sedatives
Psychosis/delirium tx in PD
-reduce PD med dose
-pimavanserin (newish antipsychotic for psychosis
-atypical antipsychotics (clozapine, quetiapine)
-AVOID: haloperidol, olanzapine, paliperidone, risperidone
