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PT2 Neuro 6-9 > PD therapeutics > Flashcards

PD therapeutics Flashcards

1
Q

motor symptoms of parkinson’s

A
  • resting tremor
  • bradykinesia
  • rigidity
  • postural instability
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2
Q

musculoskeletal symptoms of parkinson’s

A
  • dysarthria (speech problems)
  • dysphagia (can’t swallow)
  • hypophonia (talk quietly)
  • flexed posture
  • micrographia (small writing)
  • diminished arm swing
  • difficulty turning in bed
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3
Q

gait symptoms of parkinson’s

A
  • shuffling
  • freezing at initiation of movement
  • festinating gait (trouble starting/stopping)
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4
Q

other non-motor symptoms of parkinson’s

A
  • urinary urgency
  • ED
  • drooling
  • cognitive dysfunction
  • mood disorders
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5
Q

current therapies only treat the…

A

symptoms

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6
Q

goals of PD treatment

A
  • restore dopamine/ACh balance

- manage associated symptoms of PD

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7
Q

things to consider in drug therapy of PD

A
  • Pts. current signs and symptoms
  • age and stage of disease
  • degree of functional disability
  • level of physical activity and productivity
  • Pts. desires
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8
Q

how to start a new drug for PD

A

start low and titrate slow

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9
Q

why do we not give straight dopamine as a therapy

A

it doesn’t cross the BBB

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10
Q

L-dopa is usually given with what

A

carbidopa (and sometimes entacapone) to prevent L-dopa metabolism in the periphery

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11
Q

levodopa MoA

A

dopamine precursor

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12
Q

carbidopa MoA

A

decarboxylase inhibitor (prevents conversion of L-dopa to dopamine in the periphery)

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13
Q

kinetics problem with levodopa monotherapy

A

highly metabolized so only 1% reaches brain

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14
Q

carbidopa/levodopa is useful for…

A

treating motor symptoms associated with PD

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15
Q

carbidopa/levodopa dosing

A

individualized to the patient
carbidopa ~25 mg/dose
levodopa ~100 mg/dose

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16
Q

carbidopa/levodopa immediate release brand name

A

Sinemet

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17
Q

carbidopa/levodopa dosage forms

A
  • immediate release
  • controlled release
  • ODT
  • extended release
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18
Q

main problem with long term use of levodopa

A

patients will develop dyskinesias after 2-7 years

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19
Q

most effective treatment for symptoms of PD

A

levodopa

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20
Q

issues in levodopa use

A
  • on-off syndrome
  • wearing off
  • delayed response
  • freezing
  • peak dose dyskinesia
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21
Q

how to deal with “wearing off” of levodopa

A

use in combination with COMT inhibitor, MAO-B inhibitor, or dopamine agonist

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22
Q

how to prevent delayed response to levodopa

A

take on an empty stomach

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23
Q

adverse effects of carbidopa/levodopa

A
  • orthostatic hypotension
  • N/V
  • dyskinesias
  • anxiety, confusion, hallucinations, depression
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24
Q

neurologic side effects of carbidopa/levodopa usually occur when

A

when you first start the dose or increase the dose

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25
Q

drug interactions with carbidopa/levodopa

A
  • cocaine, MAO-I
  • antipsychotics
  • antihypertensives
  • pyridoxine or vit. B6
  • protein
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26
Q

contraindications with carbidopa/levodopa

A

hypersensitivity

narrow-angle glaucoma

27
Q

MAO-B inhibitors

A

selegiline (Eldepryl)

rasagiline (Azilect)

28
Q

MAO-B inhibitors MoA

A

selective inhibit MAO-B in the CNS to block dopamine degradation

29
Q

MAO-B monotherapy

A
  • can work early in therapy because it can cross the BBB and works within dopamine neurons
  • still usually used w/ carbidopa/levodopa
30
Q

advantages of MAO-B

A
  • potentially reduces “on-off” phenomenon and less wearing off may also occur with lower dose
  • should lower levodopa dose to avoid dyskinesia/halllucinations*
31
Q

adverse effects of selegiline

A 
nausea
diarrhea
insomnia
hallucination/vivid dreams
confusion
32
Q

adverse effects of rasagiline

A 
arthralgia
hallucinations
dyspepsia
depression
falls
33
Q

drug interactions with MAO-B inhibitors

A

meperidine

SSRIs

34
Q

COMT inhibitors

A

tolcapone (Tasmar)

entacapone (Comtan)

35
Q

COMT inhibitors MoA

A

reversible inhibition of COMT in the periphery (and CNS for tocapone)

36
Q

COMT inhibitors monotherapy

A

not approved so don’t do it

37
Q

adverse effects of COMT inhibitors

A
  • worsen levodopa side effects
  • hepatotoxicity
  • sedation
  • diarrhea (common reason to d/c)
  • urine discoloration
38
Q

when to use COMT inhibitors

A
  • in combination with carbidopa/levodopa

- useful for wearing off and on/off phenomenon

39
Q

when to discontinue COMT inhibitors

A

if no clinical benefit is seen after 3 weeks of treatment

40
Q

dopamine agonists

A

pramipexole
robinirole
rotigotine
apomorphine

41
Q

dopamine agonist MoA

A

activate dopamine receptors (D2) to stimulate the production of dopamine

42
Q

dopamine agonist adverse effects

A
  • nausea
  • orthostasis
  • sedation
  • compulsive behaviors
43
Q

when to use dopamine agonists

A
  • in younger patients

- avoid >65 due to increased risk of orthostasis and hallucinations

44
Q

apomorphine use

A

for acute episodes of freezing

45
Q

apomorphines adverse effects

A
  • N/V so must premedicate with trimethobenzamide
  • hallucinations
  • orthostasis, somnolence
  • must give a test dose with medical supervision*
46
Q

antichonlinergics

A

benztropine

trihexphenidyl

47
Q

anticholinergics MoA in PD

A

-tries to restore ACh/DA balance in the basal ganglia

48
Q

when to use anticholinergics

A

in younger patients earlier in the disease because of the side effects

49
Q

adverse reactions of anticholinergics

A
  • dry

- confusion

50
Q

drug interactions of anticholinergics

A

levodopa (does not mean you cannot use it, just monitor for side effects due to increased concentration of dopamine)

51
Q

how to stop anticholinergics

A

taper

52
Q

amantadine MoA

A

NMDA receptor antagonist

53
Q

when to use amantadine

A
  • early in parkinsons for akinesia or rigidity

- may suppress levodopa-induced dyskinesia

54
Q

amantadine dosing

A

according to their CrCl because it is cleared renally

55
Q

contraindications of amantadine

A

seizures

CHF

56
Q

adverse effects of amantadine

A
  • anticholinergic
  • dizziness
  • edema
  • confusion
  • hallucinations
  • “livedo reticularis”
57
Q

drug interaction of amantadine

A
  • triamterene

- trimethoprim

58
Q

non-pharmacologic treatments of PD

A
  • education
  • physical therapy
  • exercise
  • occupational therapy
  • medical nutrition therapy
  • support groups
  • deep brain stimulation
59
Q

treatment plan for those under 65 y/o

A
  • Mild or early PD: rasagiline or amantadine, anticholinergics if tremor
  • moderated-advanced: DA agonists, levodopa/carbidopa and eventually COMT or MAO-B inhibitor to reduce wearing off
60
Q

treatment plan for those over 65 y/o

A
  • levodopa/carbidopa or MAO-Bs if early in PD
  • eventually add COMT or MAO-B to reduce wearing off
  • amatadine to reduce dyskinesia
  • avoid DA agonists and anticholinergics
61
Q

when do we consider drug therapy

A

when disease is interfering with activities in life

62
Q

why use anticholinergics in PD

A

to reduce mild tremors

63
Q

most effective medicaiton for symptomatic treatment of PD

A

carbidopa/levodopa

64
Q

how to start/stop any PD drug

A

always titrate/taper

PT2 Neuro 6-9 (5 decks)

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