Parkinsons disease

Question 1

What is Parkinson’s disease ?

Answer 1

is a progressive neurodegenerative condition resulting from the death of dopaminergic cells of the substantia nigra in the brain.

Question 2

Patients with Parkinson’s disease classically present with what type of symptoms ?

Answer 2

motor-symptoms including hypokinesia, bradykinesia, rigidity, rest tremor, and postural instability.

Question 3

What are the non-motor symptoms in Parkinson’s disease?

Answer 3

Non-motor symptoms include dementia, depression, sleep disturbances, bladder and bowel dysfunction, speech and language changes, swallowing problems and weight loss.

Question 4

When Parkinson’s disease diagnosis is confirmed, patients should be advised to inform who ?

Answer 4

the DVLA and their car insurer.

Question 5

What is first-line treatment in drug management of motor symptoms in Parkinson’s disease ?

Answer 5

In early stages of Parkinson’s disease, patients whose motor symptoms decrease their quality of life should be offered levodopa combined with carbidopa (co-careldopa) or benserazide (co-beneldopa).

Parkinson’s disease patients whose motor symptoms do not affect their quality of life, could be prescribed a choice of levodopa, non-ergot-derived dopamine-receptor agonists (pramipexole, ropinirole or rotigotine) or monoamine-oxidase-B inhibitors (rasagiline or selegiline hydrochloride).

Question 6

What are the adverse reactions from antiparkinsonian drugs ?

Answer 6

psychotic symptoms, excessive sleepiness and sudden onset of sleep with dopamine-receptor agonists, and impulse control disorders with all dopaminergic therapy (especially dopamine-receptor agonists).

Question 7

With what complications is LEVEDOPA treatment associated ?

Answer 7

motor complications, including response fluctuations and dyskinesias. Response fluctuations are characterised by large variations in motor performance, with normal function during the ‘on’ period, and weakness and restricted mobility during the ‘off’ period. ‘End-of-dose’ deterioration with progressively shorter duration of benefit can also occur. Modified-release preparations may help with ‘end-of-dose’ deterioration or nocturnal immobility.

Question 8

The overall improvement in motor performance is more noticeable with which antiparkinsonian drugs?

Answer 8

with levodopa than with dopamine-receptor agonists,

Question 9

Motor complications are less likely to occur with which antiparkinsonian drugs when treated long term ?

Answer 9

dopamine-receptor agonists

Question 10

Excessive sleepiness, hallucinations, and impulse control disorders are more likely to occur with which antiparkinsoniai drug ?

Answer 10

with dopamine-receptor agonists than with levodopa.

Question 11

What is the risk if antiparkinsonian drugs are poorly absorbed or are abruptly withdrawn ?

Answer 11

potential for acute akinesia or neuroleptic malignant syndrome

Question 12

Patients who develop dyskinesia or motor fluctuations despite optimal levodopa therapy should be offered a choice of which antiparkinsonian drugs?

Answer 12

non-ergotic dopamine-receptor agonists (pramipexole, ropinirole, rotigotine),
monoamine oxidase B inhibitors (rasagiline or selegiline hydrochloride)
or COMT inhibitors (entacapone or tolcapone) as an adjunct to levodopa.

Question 13

When would ergot-derived dopamine receptor agonist can be considered as an adjunct to levodopa ?

Answer 13

only if symptoms are not adequately controlled with a non-ergot-derived dopamine-receptor agonist ( pramipexole, ropinirole, rotigotine )

Question 14

If dyskinesia is not adequately managed by modifying existing therapy, what other drug can be considered ?

Answer 14

amantadine

Question 15

What are the first line options for nocturnal akinesia ?

Answer 15

levodopa or oral dopamine-receptor agonists .

rotigotine as second-line (if both levodopa or oral dopamine-receptor agonists are ineffective).

Question 16

What is the first and second line treatment in postural hypotension ?

Answer 16

midodrine hydrochloride should be considered as the first option and fludrocortisone acetate [unlicensed indication] as an alternative.

Question 17

What drug can be used to treat psychotic symptoms In Parkinson’s disease patients with no cognitive impairment ? What would be an alternative drug ?

Answer 17

Quetiapine
If standard treatment is not effective, clozapine should be offered to treat hallucinations and delusions in patients with Parkinson’s disease.

Question 18

Which antipsychotics can worsen the motor features of Parkinson’s disease?

Answer 18

phenothiazines and butyrophenones

Question 19

What drug is used to treat rapid eye movement sleep behaviour disorder?

Answer 19

Clonazepam [unlicensed indication] or melatonin [unlicensed indication]

Question 20

First line treatment for drooling of saliva ?

Answer 20

Glycopyrronium bromide [unlicensed indication] should be considered as first-line treatment and botulinum toxin type A [unlicensed indication] as second-line.

Question 21

Patients with advanced Parkinson’s disease can be offered which drug ?

Answer 21

can be offered apomorphine hydrochloride as intermittent injections or continuous subcutaneous infusions

Question 22

Which drug can be used To control nausea and vomiting associated with apomorphine?

Answer 22

domperidone [unlicensed in those weighing less than 35 kg] will usually need to be started two days before apomorphine therapy, and then discontinued as soon as possible.

Question 23

What is interaction between apomorphine and domperidone ?

Answer 23

risk of serious arrhythmia due to QT prolongation

Question 24

if the patient has a history of previous impulsive behaviours, alcohol consumption, or smoking and are taking any of the dopaminergic drugs they are at risk of ?

Answer 24

Impulse control disorders (compulsive gambling, hypersexuality, binge eating, or obsessive shopping) can develop in a person with Parkinson’s disease who is on any dopaminergic therapy at any stage in the disease course

Question 25

name all monoamine-oxidase b inhibitors ?

Answer 25

rasagiline, selegiline ( metabolises to amphetamine-drugs and driving ) , safinamide

Question 26

Give examples of Parkinson’s disease motor symptoms ?

Answer 26

hypokinesia, Bradykinesia, rigidity, rest tremor, postural instability

Question 27

Give examples of Parkinsons disease non-motor symptoms?

Answer 27

dementia, depression, sleep disturbances, speech and language change, swallowing problems and weight loss

Question 28

Types of Levedopa ?

Answer 28

Co-bendelopa ( levodopa with benserazide )
Co-careldopa ( levodopa with carbidopa )
Levodopa associated with more motor complications

Question 29

Name ergot derived dopamine receptor agonist?

Answer 29

bromocriptine, cabergoline, pergolide. They are usually not recommended, associated with fibrotic reactions.

Question 30

Name non-ergot derived dopamine receptor agonist ?

Answer 30

pramipexole, ropinirole, rotigotine

Question 31

name COMT inhibitors?

Answer 31

Entacapone ( colours urine ) tolcapone ( hepatotoxic ). Given adjunct to levodopa for end of dose motor fluctuations

Question 32

MOA of LEVEDOPA ?

Answer 32

acts by replenishing depleted dopamine levels in the brain . Overall improvement in motor performance is more noticeable with levodopa than with dopamine-receptor agonists.

Question 33

Why levedopa is given with peripheral dopa-decarboxylase inhibitors ?

Answer 33

less side effects: nausea, vomiting, cardiovascular effects and lower dose required

Question 34

What are the main side effects of levodopa therapy ?

Answer 34

• impulse control disorders,
• excessive sleepiness and sudden onset of sleep
• motor complications ( dyskinesia )
• Response fluctuation ( ‘‘ON’’ period = normal function and OFF period =weakness and restricted mobility )
• End of dose deterioration= MR release preparations may help

Question 35

MOA of Dopamine receptor agonists ?

Answer 35

direct action on dopamine D2 receptors in stratium.

Has more risk of hallucinations, excessive sleepiness and impulse control disorders than levodopa.

Question 36

Ergot derived dopamine rector agonists side effects?

Answer 36

fibrotic reactions ( excess fibrous tissue forms on organs )

• plumonary ( dyspnoea, persistent cough )
• Retroperitoneal ( abdominal pain and tenderness )
• Pericardial ( cardiac failure )

Question 37

What are the side effects of dopamine receptor agonists ?

Answer 37

• Impulse control disorders
• excessive sleepiness and student onset of sleep
• psychotic symptoms; hallucinations and delusions
• Hypotensive reaction in first few days ( warning for driving )

Question 38

MOA of MAO-B inhibitors ?

Answer 38

inhibits monoamine oxidase b enzymes which are responsible for the breakdown of monoamines; dopamine

Question 39

Interactions of MAO-B inhibitors that can lead to hypertensive crises ?

Answer 39

Pseudoephederine, pheylepehrine, xylometalozine, oxymetazoline, adrenaline, noradrenaline, methylphenidate, amphetamines, B2 agonists ( drugs that increase BP; sympathomimetics )
Tyramine rich foods

Question 40

What are the uses of COMT inhibitors ?

Answer 40

Adjunct to levodopa in ‘‘end - of -dose ‘’ motor fluctuations

Question 41

Which COMT inhibitor colours urine reddish- brown ?

Answer 41

Entacapone

Question 42

Which COMT inhibitor causes hepatoxicity ?

Answer 42

Tolcapone ( during first six months of treatment )

Question 43

What are the signs of liver toxicity ?

Answer 43

anorexia, nausea, vomiting, abdominal pain, dark urine, pruritus

Question 44

COMT inhibitor interactions that lead to an Increase in heart or blood pressure ?

Answer 44

adrenaline, noradrenaline, MAOIs

Question 45

What should be done when switching patients from another levodopa/dopa-decarboxylase inhibitor preparation ?

Answer 45

the previous preparation should be discontinued at least 12 hours before.

Question 46

What Cautionary and advisory labels should include when dispensing levodopa ?

Answer 46

Label 10 - Warning: Read the additional information given with this medicine
Label 14 - This medicine may colour your urine. This is harmless

Question 47

A 65-year-old woman attended at the hospital for a medical review. She is known to suffer from Parkinson’s disease and she is currently taking co-careldopa 25/100 mg 8 times a day. You complete a full medication review and noted that she has developed dyskinesia and motor flactuation. What add-on treatment would you most recommend?

Answer 47

E;rotigotone; non ergot dopamine receptor agonist; If dyskinesia or motor fluctuations despite optimal levodopa therapy offer: •non-ergotic dopamine-receptor agonists (pramipexole, ropinirole, rotigotine) •monoamine oxidase B inhibitors (rasagiline or selegiline hydrochloride) •COMT inhibitors (entacapone or tolcapone) •Only offer ergot-derived dopamine-receptor agonist (bromocriptine, cabergoline or pergolide) as an adjunct to levodopa if symptoms are not adequately controlled with a non-ergot-derived dopamine-receptor agonist •If dyskinesia is not adequately managed by modifying existing therapy, amantadine hydrochloride should be considered