Parkinsons Disease Flashcards
EOR exam 5
1
Q
What is parkinson’s Disease?
A
- A degenerative neurological disorder.
- PD occurs when neurons die in the basal ganglia which includes the substantia nigra.
- These cells produce dopamine which enables smooth coordinated muscle function and movement
- PD motor sx occur when 80% of DA cells are damaged
2
Q
what are the TRAP disease symptoms
A
- T: Tremor: when resting
- R: Rigidity: in legs, arms, trunk and face (mask-like-face)
- A: Akinesia/Bradykinesia: lack of/ slow start in movement
- P: Postural instability: Imbalance, falls
3
Q
what are the ‘additional’ sx of PD?
A
- Small cramped handwriting (Micrographia)
- Shuffling walk, stooped posture
- Muffled speech, drooling, dysphagia
- Depression, anxiety (psychosis in advanced disease)
- Constipation, incontinence
4
Q
What can be used to measure involuntary movements from medications?
A
- The abnormal involuntary movement scale (AIMS)
5
Q
what drugs can worsen PD?
A
- Phenothiazines
a. Prochlorperazine (compazine)
b. Chlorpromazine - Butyrophenones
a. Haloperidol
b. Droperidol - First and second-gen antipsychotics
a. Risperidone, paliperidone
b. quetiapine lowest risk - Metoclopramide (reglan) (renally cleared drug that can accumulate in older adults)
6
Q
what is “off time” in PD?
A
- This is when symptoms of the disease worsen before the next dose of medication is due
- An “off” episode with muscle stiffness is one of the most frustrating aspects of living with the disease
7
Q
what can patients with PD use to treat depression?
A
- SSRI and SNRI are commonly used for treatment
- TCA’s preferably secondary amines (desipramine and nortriptyline)
8
Q
what are the preferred medications in treating psychosis with PD?
A
- Quetiapine is the preferred antipsychotic due to a low risk of movement disorders, but can cause metabolic complications (increased cholesterol + BG)
- Clozapine has low risk of worsening movement disorders but has a high risk of seizures, agranulocytosis.
- Pimavanserin (Nuplazid) FDA approved to txt hallucinations in PD
9
Q
What can abrupt withdrawal of levodopa or dopamine agonist cause?
A
- Lead to a condition similar to neuroleptic malignant syndrome (NMS), which is a life threatening condition
- These medications must be slowly tapered with d/c to prevent NMS
10
Q
what is the most effective agent in treating PD?
A
- Levodopa a prodrug of dopamine
11
Q
Why is carbidopa given with levodopa?
A
- To prevent the breakdown of levodopa outside of the CNS (peripheral metabolism) which would destroy most of the drug before it crosses the blood brain barrier.
12
Q
what is the indication of centrally acting anticholinergics in PD?
A
- Reducing acetylcholine activity within the CNS, which reduces motor symptoms
- These are used for tremor predominant disease in younger patients
13
Q
Why are anticholinergics difficult to use in older adults?
A
- The considerable side effects of these drugs make them difficult to use in older adults
- Beers criteria for potentially inappropriate medication use in older adults recommends to avoid use
14
Q
what is the indication for Amantadine?
A
- Can be useful to help with dyskinesias in addition to tremor
15
Q
what is the indication of Apomorphine
A
- Treats severe freezing episodes that usually occur in more advanced disease but requires Subcutaneous injection
16
Q
what is Droxidopa?
A
- (Northera) is a newer drug indicated for orthostatic hypotension which can affect PD patients
17
Q
what is the MOA of sinemet
A
- Levodopa is a precursor of dopamine
- Carbidopa inhibits the dopa decarboxylase enzyme preventing peripheral metabolism of levodopa
18
Q
what is the dosing for sinemet
A
- Titrate cautiously
- IR: 25/100 mg PO TID
- ER tab can be cut in half do not crush or chew
19
Q
what is Rytary and the counseling points?
A
- ER capsule of levodopa/ carbidopa
- Take whole or sprinkle on a small amount of apple sauce
20
Q
what are the contraindications with Sinemet?
A
- Use of Non selective MAO inhibitors within 14 days
-Phenelzine (Nardil)
-Tranylcypromine (Parnate)
-Isocarboxazid (Marplan)
-Selegiline – at high doses (Emsam)
21
Q
What are the side effects of Sinemet?
A
- Nausea
- Dizziness
- orthostasis
- dyskinesias
- hallucinations
- Psychosis
- Brown, black, or dark discoloration of urine, saliva or sweat
- Positive coombs test: d/c the drug (hemolysis risk)
- unusual urges, priapism
22
Q
how much carbidopa is required to inhibit dopa decarboxylase ?
A
- 70-100 mg a day
23
Q
what is the MOA of COMT inhibitors?
A
- Increase the duration of action of levodopa
- Inhibit the enzyme catechol-o-methyltransferase (COMT) to prevent peripheral conversion of levodopa.
- COMT inhibitors should only be used with levodopa
24
Q
what is the drugs of the class COMT inhibitors?
A
- Entacapone (comtan) 200 mg with each dose of sinemet
- Opicapone
- Tolcapone
25
what is the MOA of dopamine agonists
1. Act similar to dopamine at the dopamine receptor
26
what are the drugs of the dopamine agonist class?
1. Pramipexole (Mirapex, Mirapex ER)
2. Ropinirole (Requip )
3. Rotigotine (Neupro)
27
what other indication are dopamine agonist all approved for?
IR formulations also approved for RSL
28
what are the warnings with dopamine agonist ?
1. Somnolence (including sudden daytime sleep attacks)
2. Orthostasis
3. Hallucinations
4. Dyskinesias
Rotigotine patch: Application site (skin) reactions
29
What are the counseling points for the rotigotine patch?
1. Apply once daily at the same time each day to the stomach, thigh, hip, side of body, shoulder, or upper arm
2. Do not use the same site for at least 14 days
3. Remove the patch before an MRI
4. Avoid if sensitivity/ allergy to sulfites
30
what is the class and MOA of apomorphine ?
1. Dopamine agonist
2. Used as a rescue movement drug for off episodes
31
Apomorphine has what specific requirement for the initial dose?
1. Must be started with a test dose in a medical office
32
what are contraindications to the use of Apomorphine ?
1. Do not use with 5-HT3 antagonists (ondansetron) due to severe hypotension and loss of consciousness
33
what are the side effects of Apomorphine?
1. severe N/V
2. Hypotension
34
what can be used as emesis prevention when using Apomorphine
1. Trimethobenzamide (Tigan)
35
what is the MOA of Amantadine?
1. Blocks dopamine reuptake into presynaptic neurons and increases dopamine release from presynaptic fibers
36
what is the primary use for Amantadine?
1. Primarily used to treat dyskinesias associated with peak dose of sinemet
37
what are the side effects of Amantadine ?
1. Dizziness
2. Orthostatic hypotension
3. cutaneous reaction called livedo reticularis (reddish skin mottling)
38
what is the MOA of selective MAo-B inhibitors in PD?
1. Block the breakdown of dopamine which increases dopaminergic activity
39
what is the indication for selective MAO-B inhibitors ?
1. Primarily used as adjunctive treatment to sinemet
40
what are the drugs of the class selective MAO-B inhibitors?
1. Selegiline - can be activating do not take dose at bedtime
2. Rasagiline
3. Safinamide
41
what are the contraindications of MAO-B inhibitors?
1. Use in combination with other MAO inhibitors including linezolid, opioids, SNRIs
2. Xadago (safinamide): severe hepatic impairment
42
what are warnings with MAO-B inhibitors?
1. Serotonin syndrome
2. Hypertension
43
what are the drugs of the centrally acting anticholinergic class?
1. Benztropine (Cogentin)
2. Trihexyphenidyl
44
what is the side effects of centrally acting anticholinergics ?
1. Dry mouth
2. Constipation
3. Urinary retention
4. Blurred vision
5. Mydriasis
6. Somnolence
7. Confusion
45
what is Istradefylline (iss-truh-DEH-fill-een)
1. Adenosine receptor antagonist used
2. used in combination with sinemet to reduce off episodes
3. Nourianz
46
what is droxidopa ?
1. Alpha/Beta agonist
2. Used for neurogenic orthostatic hypotension
47
what are the side effects of Droxidopa?
1. Syncope
2. Falls
3. Headache
48
what are the drug interactions with MA)-B inhibitors?
1. food high in tyramine such as:
2. aged or matured cheese
3. air dried or cured meats (sausages, salamis)
4. sauerkraut
5. Do not use with other drugs that can increase risk of serotonin syndrome
