PBL 3- Parkinsons/Huntingtons Flashcards

1
Q

What are tandom repeats?
What are the different types?
What happens when you have too many?
What kind of symtpoms do you get?

A
  • The human genome has many repeated DNA sequences of unknown or NO function
    • They can be of any length
    • A dinucleotide repeat is CGCGCGCG
    • An excessive amount of repeats within a gene can disrupt the protein encoded by the gene
    • This can lead to a SINGLE gene disorder
    • Trinucleotide repeats “triplet” repeats can cause various human genetic disease
    • Symptoms can vary greatly depending on which gene is disrupted

If different genes ultimately affect the same system then a mutation in any of these genes alone can lead to a clinically similar disease

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2
Q
What is Fragile X syndrome:
What are the main features?
What type of  mutation causes it?
What gene does it effect?
What is the usual function of that gene?
How do different amounts of repeats present?
A

Fragile X syndrome:

- Moderate to severe mental retardation
- Macroorchidism (large testicles)
- Distinct facial features- long face, large ears, prominent jaw

Large number of repeats =

> 200 CGC repeats in the fragile mental retardation 1 gene (FMR1)

- Encodes an RNA binding protein believed to be involved in transation
- Large number of repeats leads to a loss of function of the FRMI gene

Shorter expanded CGC repeats (55-200)

- Termed premutations 
- Can give rise to Fragile X mutations in subsequent generations by expansion of the repeats
- Cause a GAIN of function  Protein levels are not much affected but the longer mRNA appears to cause nuclear damage leading to degeneration
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3
Q

What is Ataxia?

What is some genetic causes?
What are the types?

A

Ataxias

means

- Incoordination and unsteadiness due to the brains failure to regulate posture and limb movements appropriately
- Often due to diseases affecting the cerebellym
- Can have early or late onset (before or after 20-25)

Early onset forms:

- Usually autosomal recessive
- EG = Friedrichs ataxia, usually involving triplet repeat mutations of the frataxin gene

Late onset: EG spinocerebellar ataxia
- Usually autosomal dominant
- All common forms SCA1 are due to triplet repeats
- Gait and balance impairments
- Other symptoms can include peripheral neuropahty, dementia, ophthalmaplegia
- Degeneration of the cerebellum and afferent/efferent connections in the brainstem and spinal cord
- SCA1= CAG triplet repeats in ATAXIN 1 function unknown but appears to be involved in cerebellar development
SCA6- most commonly due to CAG triplet repeats in a calcium channel gene CACN11A (single point mutation causes familial hemiplegic migraine)

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4
Q

What is Kennedy spinal and bulbar muscular atrophy?

What kind of mutation causes it?

A
  • Triplet repeats in an androgen receptor
    • Single point mutation in the same place causes very different disease- adrogen insensitivity syndrome- where chromosomal males can a female phenotype
    • Myotonic dystrophy: MD1- dystrophia myotonica- protein kinase gene
      MD2- zinc finger protein 9 gene
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5
Q

Generally, what is Huntingtons disease?

A

Fatal, adult onset neurodegenerative disease with movement chorea and cognitive symptoms

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6
Q

What genetic mutation causes it?

ie - what nucleotide pattern?
what does it code for? and what gene does it effect?

A
  • Multiple repeats of the trinucleotide CAG In the coding region of the HTT gene
    • Gene: IT15 gene encoding the huntingtin protein
    • CAG encodes the amino acid glutamine (symbol Q)
    • This causes multiple Q repeats in huntingin (also called polyglutamine or polyQ disease)
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7
Q

What inheritance pattern does Huntingtons follow?

when is it inherited in a more unstable fashion?

A

Autosomal Dominant

which is more unstable when inherited by the father

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8
Q

how many alleles need to be abnormal to inherit Huntingtons disease?

A

One

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9
Q

Does the Huntingtin protein end up with a loss or gain of function in HD?
What would happen if it was the other?

A
  • Loss of function mutation in the HD gene causes fetal death not Huntingtons disease
    • Expansion of CAG repeats causes a GAIN of function mutation
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10
Q

What is Anticipation?
Why does it occur?
How does it effect people clinically?

A
  • Repeat sequences usually inherited in a stable fashion but can become unstable with increased repeats in offspring
    • Expansion is probably due to slippage of DNA polymerases during DNA synthesis○ The enzyme “loses track” of where it is in the region of the repeats and incorporates more repeats
    • Slippage in DNA replication in succeeding generations can cause increased disruption of the gene
      This increases symptom severity and typically results in earlier onset of disease in children in comparison to their parents
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11
Q

How are trinucleotide repeats trasmitted?
ie in what stage of life?
does it have a bias?

A
  • Repeat expansion occurs during gametogenesis, can also occur during spermatogenesis
    • Repeat expansion shows a sex bias
    • Occurs in three forms
      ○ Normal : number of repeats in stable and no change during gametogenesis
      ○ Pre-mutaiton: partially expanded = no symptoms however unstable during gametogenesis

Full mutation: symptoms

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12
Q

Why is the number of repeats important?

Do normal people have repeats?

How many repeats is needed to transmit or develop disease?

A
  • Everyone has a few multiple CAG repeats in the huntingtin gene however the number is important for disease penetrance
    • The more repeats the more abnormal the protein product, the more severe the symptoms and the earlier the age of onset.
    • Has a dose effect
    • 28 or less = normal range
    • 29-34 = wont get HD but next generation is at risk
    • 35-39 = Some will get HD but not all. Next generation at risk
      More than 40 = Will get HD
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13
Q

When is the normal onset for Huntington’s?

when would you get it earlier?

A
  • Usually in your 30s to 40s however the range can be from 2-82 years of age
    • The onset usually gets younger with each generation (anticipation) and also there is earlier detection
    • Over 60 repeats of CAG is associated with onset before age 20
    • Usually more repeats = more severe disease however if your number of repeats is under 60 then it is highly variable
      ○ Likely to reflect modifying effects of other genetic and/or environmental factors
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14
Q

Is Parkinsons homogenous or heterogenous?

Whats the difference between monogenic forms and multifactorial forms of PD?

A
  • Complex heterogenous genetic disease
    • Distinct Parkinson’s disease subtypes with distinct genetic aetiologies, pathologies and symptoms
  • Deficit of the NT-dopamine

No clear inheritance pattern

- Monogenic forms of PD caused by a mutation in a single gene
	○ Mutations in several different genes can each individually give rise to Parkinsons disease  ie each such mutation is sufficient but not necessary for development of parkinson's disease 

Multifactorial forms of
Parkinson’s Disease- reflecting multiple genetic and or environmental factors and their interactions.

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15
Q

What causes monogenic forms of parkinsons disease?

What are some gene examples?

A
  • Caused by a mutation in a single gene
    • A-synuclein, Nurr1, Parkin- can each individually give rise to parkinson’s
    • Various genetic loci (PARK 3, PARK 20 ) are linked to parkinson’s disease but the specific genes at these chromosomal locations that are causing the effects of the disease have not been identified.
      SNCA, LRRK2, PINK1 have also been implicated in sporadic PD
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16
Q
PARKIN gene
What chromosome and loci?
what kind of parkinsons is it associated with?
how common?
when is the onset and progression?
what does Parkin usually do?
what does a mutation result in?
A

Parkin ( Chromosome 6, PARK 2)

  • Implicated in autosomal recessive juvenile parkinsonism
    • Rare
    • Onset <40 years
    • Slow course over decades
    • Loss of nigral dopaminergic neurons but usually NO Lewy bodies or Lewy Neurties
    • Over 1000 single nucleotide polymorphisms so far identified in the parkin gene
      ○ Some are harmless
      ○ Some may causes PD when homozygous
    • Parkin is an E3 ubiquitin ligase- it attaches short ubiquitin peptide chains to proteins to tag them for degradation through the proteasome pathway
    • Parkin is involved in degradation of at least one form of synuclein and of at least one other neuronal protein that binds to a-synuclein
      Mutations in parkin are likely to affect degradation of a- synuclein
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17
Q

A-Synuclein

What chromosome
what loci?
What kind of inheritance pattern?
What kind of progression ?
where is the mutation site?
A

(Chromosome 4, PARK 1/4)
- Autosomal dominant mutations in a-synuclein found in rare familial early onset forms of PD
- Rapid progresion and cognitive impairment
- Several different mutation sites in the a-synuclein gene
Mutation causes aggregation of the a-synuclein protein in lewy bodies

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18
Q
Leucine rich repeat Kinase 2 Lrrk2
What does it usually encode for?
What is the function usually?
What kind of inheritance pattern/
what kind of pathology does it produce?
how much parkinsons is cuased by this type?
A

(Chromosome 12; PARK 8)

  • Encodes “dardarin” protein
    • Function unnown but interacts with parkin and may affect normal functioning or maintenance of the dopaminergic system
    • Autosomal dominant inheritance
    • Mutation in Lrrk2 may account for 10% of autosomal dominant PD
    • Accounts for at least 7% of late onset familial PD and a sproportion of sporadic PD
    • There is a wide range of pathologies- which can differ even within families
19
Q

What does the mutation in the Huntingtin gene cause?

A

causes polyglutamine tracts that aggregate together

aggregates accumulate in cells and interfere with normal function

20
Q

What are candidate susceptibility factors?

What are some examples for parkinson’s disease

A

Susceptibility factors modify the risk of developing a disease but are not alone sufficient to cause a disease

For PD these could include mutations in proteins involved in:

  • Dopamine-related systems
  • Iron handling
  • The ubiquitin-proteasome protein degradation system
  • Energy supply (e.g. mitochondrial function) and/or oxidative stress
  • Inflammation
  • Detoxification of metabolites & xenobiotics (such as pesticides)
  • Chaperone proteins such as certain heat shock proteins that help to fold proteins correctly
21
Q

What is Parkinson’s disease?
What does it lead to?
What are the treatment aims?

A
  • Neurodegeneration of dopaminergic neurons in the substantia nigra pars compacta
    • This leads to reduces levels of dopamine in the basal ganglia
    • Results in a hyperactivity of the striatum cholinergic neurons
    • Increases GABAergic inhibition of the thalamus and cortex
    • Ultimately leads to muscle rigidity
    • Process is irreversible
    • Symptom management is the current treatment
    • Management targets aim to increase dopamine and decrease cholinergic activity
22
Q

Where does Dopamine come from?

A
  • Tyrosine is an aromatic amino acid present in body fluids and taken up by nerve terminals
    • Tyrosine hydroxylase is only found in catecholamine containing cells
    • This converts tyrosine to DOPA (this is the rate limiting step)
    • DOPA decarboxylase then converts DOPA into Dopamine
    • If dopamine is acted on by dopamine B-Hydroxylase it is converted into Noradrenaline
      Can also be further metabolised into Adrenaline
23
Q

How is dopamine normally metabolised?

A
  • Two enzymes target dopamine
    ○ Catechol-O-methyl transferase (COMT)
    MAO- Monoamine transferase
24
Q

What is Levadopa?

A

Dopamine precursor

25
Q

Why is it used instead of dopamine?

A

It can cross the BBB whereas Dopamine cannot.

It is used as a dopamine replacement therapy

26
Q

What is Levodopa administered with and why?
Where does this act?
What result does this have?

A
  • Levadopa is readily absorbed by the small intestine by active transport
    • Plasma half life is 1-3 hours
    • Readily metabolised by the MOA-A in the wall of the small intestine before it is able to enter the CNS
    • Aromatic L-Amino acid decarboxylases in the periphery convert most of the remaining levodopa to dopamine before it crosses the BBB
      This means it is not given via sublingal route- too much peripheral metabolism
27
Q

How much Levodopa reaches the CNS if given alone?

A

1-3%

28
Q

Side effects if Levadopa given alone?

A
  • Reduced levodopa reaching the brain

More peripheral metabolism results in stimulation of D2 receptors in the GIT

29
Q

What is Levodopa Co Administered with?

What is the result of this?

A
  • Dopa decarboxylase inhibitors
    ○ Carbidopa or benserazide
    • These drugs cannot cross the BBB therefore only have a peripheral effect and will not stop conversion to dopamine once Levadopa has crossed the BBB.
    • Stop the conversion of levodopa to dopamine in the periphery
    • Plasma levels of levodopa are higher
    • Plasma Half life is longer
    • More levodopa enters the CNS
    • Overall effects is to increase the bioavailability of levodopa in the CNS and prolong its action
      When using with Dopa decarboxylase inhibitors about 10% reaches the brain
30
Q

Adverse effects of Levodopa

A

GIT
- Stimulation of emetic centre in the brain stem out side the BBB
- Occurs less when combined with Dopa Decarboxylase inhibitors
○ Cannot use metaclopromide because it crosses BBB and blocks effects of levodopa
○ Domperidone is peripherally acting dopamine antagonist so is useful to prevent side effects
Cardiovascular
- Orthostatic hypotension (common
- Cardiac dysrhythmias (low incidence)
- Due to increases in catecholamine levels in periphery (from peripheral dopamine metabolism)
- Occurs less when combined with dopa decarboxylase inhibitors
Dyskinesias
- Involuntary writhing movements of face and limbs
- Develop in about 80% of long term users of levodopa
- Could be due to fluctuations in availability of conversion enzymes etc
- Dose dependent
- On-off effects - from total rigidity to improved mobility and marked dyskinesia
Nervous system /psychiatric
- Psychotic episodes including delusions, hallucinations and paranoid ideation
- Also confusion, agitation, dizziness, somnolence, dream abnormalities, insomnia
- Due to excess dopamine in the mesolimbic regions of the brain- thought to cause psychosis in schizophrenia (mesolimbic system is not the target area in parkinsons treatment)
- Occurs MORE when combined with dopa dearboxylase inhibitors due to increased levels of dopamine in the brain
○ Atypical antipsychotics can be useful in treating these symptoms
○ Should adjust levodopa dose before adding more drugs to regime

31
Q

Which side effect of Levodopa is INCREASED when treatment is combined with a dopa decarboxylase inhibitor?

A

Nervous system and psychiatric symptoms- due to increased dopamine in the mesolimbic system

32
Q

Dopamine receptor agonists - mechanism of action and examples?

A
  • Bind to the D2 receptors to stimulate release of dopamine
    • Able to cross BBB- do not require activation by Dopa decarboxylase
    • Eg
      ○ Apomorphine
      ○ Pramipexole
      ○ Rotigotine
      Ropinirole
33
Q

Adverse effects of Dopamine receptor agonists

A
Similar side effect profile to levodopa
GIT: 
	- Nausea
	- Vomiting
	- Anorexia
	- Constipation
	- Dyspepsia
	- Gastric bleeding
Cardiovascular
	- Postural hypotension
	- Cardiac dysrhythmias
	- Peripheral oedema
Dyskinesias
CNS
Schizophrenia-like psychosis more common and severe than levodopa treatment particularly in the elderly
34
Q

Contraindications of dopamine receptor agonists

A
Patients with:
	- Psychosis
	- Myocardial infarction
	- Active peptide ulceration
Peripheral vascular disease
35
Q

What effect does blockage of dopa decarboxylase have on levodopa metabolism pathways?

A

It increases other pathways of metabolism such as COMT

36
Q

What inhibits COMT? What are the effects of this?

A
  • Entacapone
    • Prolongs the action of levodopa by reducing its peripheral metabolism
    • Decreases levodopa clearance and increases relative bioavailability of levodopa
      Adverse effects relate to increased levodopa exposure- ie dyskinesias, nausea and confusion
37
Q

Combination drugs in parkinsons treatment: -

A

Stalevo = combination of carbidopa, levodopa and entacapone
○ Carbidopa = inhibition of dopa decarboxylase
○ Entacapone = inhibitor of COMT

38
Q

What is an example of a Dopa Decarboxylase inhibitor?:

A
  • Carbidopa

Benserazide

39
Q

What is Selegiline and Rasagiline?

A
  • Monoamine oxidase B inhibitor
    ○ Acts mainly in the CNS
    ○ MOA -B is mainly found in the dopamine containing region of the CNS
    ○ It lacks the peripheral side effects associated with other MOA inhibitors which are used to treat depression because it mainly works in the CNS and does not stop peripheral break down
    ○ Protects ENDOGENOUS dopamine from degradation
    Improves motor fluctuations
40
Q

What are the limitations to parkinsons treatment?

A
  • Pharmacotherapies have reduced efficacy over time
    • Due to :
      ○ Death of dopaminergic neurons
      ○ Receptor down regulation
      Compensatory mechanisms
41
Q

What is armantadine?

A
  • First introduced as an antiviral drug
    • Increases dopamine release
    • Inhibits dopamine reuptake
    • May also act as a dopainergic agonist
    • Less effective than levodopa
      Loses efficacy over time
42
Q

What happens to Catecholamines in Parkinsons disease?

A
  • Number of cholinergic neurons does not increase
    • Because of lack of dopaminergic neurons - the predominant NT left is cholinergic
      This causes the resting tremor in parkinsons disease
43
Q

How is the resting tremor treated in parkinsons
what is the limitation?
What else are they used for?
What is an example of a drug used?

A
  • Muscarinic receptor antagonists- blocks the effect of acetylcholine
    • Used to treat tremor however does not assist with motor control
    • Also used to treat patients taking anti-pscuhotic medication (dopamine agonists) that causes PD like symptoms
    • Benztropine○ Has less peripheral side effects than atropien however not a specific receptor antagonists so blocks all muscarinic receptors causing dry mouth, urinary retention etc

Atropine- not really used any more
Benzhexol
Biperiden

44
Q

What drugs are used in Huntingtons and why?

A
  • There is an imbalance of dopamine (increased levels), acetylcholine and GABA in basal ganglia
    • Drugs that BLOCK dopamine are effective (receptor antagonists)
      ○ Haloperidol
      ○ Chlorpromazine
      Fluphenazine