Parkinsons Flashcards
Pathophysiology of parkinsons?
progressive death of dopamine neurone in substantial nigra (basal ganglia)
Role of dopamine in parkinsons?
important for smooth, controlled movements
Protective factors for parkinsons?
smoking, high coffee use
intense exercise
Hallmark movement sx of parkinsons?
Tremor
Rigidity
Akinesia
Postural instability
What do you need for diagnosis of parkinsons?
bradykinesia, tremor or rigidity, dopamine helps
What patients usually get tremors?
younger and more slow progression
What patients get the rigid subtype?
older and much more rapid progression
What can cause sx similar to parkinsons?
dopamine blocking agents such as AP and metoclopramide
When is parkisnons atypical?
if no response to levodopa
Other types of parkinsons?
Vascular and secondary due to other substances
Medications that can cause Parkinsonism?
antipsychotics
metoclopramide
lithium
VA
What antinauseant has less affects on dopamine?
domperidone
What AP has less risk for Parkinsonism?
quetiapine, clozapine
Sx of Parkinson’s in early stage?
loss of smell
constipation
depression
fatigue
act out dreams
flat affect
soft speech, dry eyes
What are later parkinsons sx?
hallucinations
drooling
sex dysfunction
urinary incontinence
orthostatic hypotension
dementia
Treatment to reduce progression of PD?
NONE
Non pharm for PD?
Physical/occupational therapy
speech therapy
psych support
hearing/vision/ dental care
Why use carbidopa/benserazide?
prevents conversion of levodopa to dopamine outside the brain= better efficacy and a/e
What is levodopa best for?
bradykinesia and rigidity
benefit in 2 weeks
What sx is levodopa not good for?
tremor, balance and non motor sx
Why do you need to taper off parkinsons meds if needed?
neurolep[tic malignant syndorme
Why titrate slow of levodopa?
nausea and gi sx
What to avoid congesting with levodopa?
protein, iron, antacids
S/e of levodopa?
gi
dizzy
fatigue
vivid dreams
What happens after around 5 years of levocarb treatment?
doesn’t last as long
inability to move
dyskinesias
When is dyskinesia the worst on levocarb?
after a dose
Other formulations of Levocarb?
enteral PEG J tube-continuous
intestinal gel
subcut infusion-continuous
Dopamine agonist drugs?
bromocriptine and carbergoline, pramipexole, ropinirol
rotigotine
Why do we never use bromocriptine and carbergoline?
ergot= pulmonary and cardio toxicity
Place in therapy for dopamine agonists?
usually younger due to tolerability in older
‘save’ levodopa
S/e of Dopamine agonists?
gi, ortho hypo, hallucination, confusion= WORSE than levodopa
drowsy
impulse control disorders!!!!!!
HUGE s/e of dopamine agonists/
impulse control issues= gambling, sexual, compulsive buys
Where is place for apomorphine?
VERY potent dopamine agonist for rescue of freezing
bad nausea though
What causes dose changes for pramipexole?
renal issues
Are dopamine agonists better than levocarb?
No
Which MAO for parkinsons?
B
MAO-B drugs?
selegiline and rasagiline
Do we need to worry about diet with MAO-B?
No as long as at PD doses
PLace in therapy for MAO-B?
only for mild
fewer s/e and less frequent dosing
may be used later to manage motor complications of levodopa
When to take MAO-B?
morning to prevent insomnia/ vivid dreams
Important DI of MAO-B?
SSRI- serotonin syndrome but is rare, DONT freak out
Bad OTC to use with MAO-B?
DM in cough suppresants= serotonin syndrome
How does entacapone work?
COMT inhibitor= stops breakdown of levocarb in periphery
What other drug must you be on if on entacapone?
levocarb duhhhh
S/e of entacapone?
gi
turn urine and sweat orange
Dose adjustment if adding entacapone?
about 30 percent
Purpose of amantadine?
for bothersome dyskinesias later in disease course
S/e of amantadine?
nausea, confusion, hallucinations
What treatment for tremor in parkinsons?
anticholinergics
Why don’t we generally use anticholinergics in parkinsons?
bad in older people
What anticholinergics for PD?
benztropine, trihexylphenidyl, procyclidine
What can we do if issues of dyskinesia on levocarb?
smaller more frequent dosing, add MAO or amantadine
What can we do to help constipation in PD?
PEG or domperidone
What can we do for depression in PD?
NO bupropion
give citalopram, sertraline, venlafaxine, duloxetine
If we do need drugs for orthostatic hypotension what can we do?
fludricortisone, domperidone
midodrine
If ED is an issue what can we do?
PDE5i- not if on ergot
What can we do for sialorrhea (less swallowing)
chew/suck on something
ipratropium
What can we do for better sleep?
melatonin, dose-in, trazadone
If sleep moving disorder what should we do for that?
NO hs AD dosing
give melatonin or benzo
How can we improve restless leg syndrome?
hs dopamine therapy, gabapentin or pregabalin
If hallucinations what can we do?
clozapine but bad s/e
quetiapine
