PD Treatment Complications and Management Flashcards
Evaluating patient’s response to L-Dopa: Stage I
patient not aware of variation in effect of an individual dose
Evaluating patient’s response to L-Dopa: Stage II
midafternoon loss of benefit requires additional dose in addition to an early AM dose
Evaluating patient’s response to L-dopa: Stage III
good response to levodopa, sleep benefit is lost, early-morning akinesia appears
Evaluating patient’s response to L-dopa: Stage IV
regular “Wearing off” every 4 or more hours, levodopa response gradually shortens
Evaluating patient’s response to L-dopa: Stage V
“Wearing off” from each dose of levodopa as well as abrupt “off” periods; patients require dosing at intervals of 2 hours or less, response to dose can be unpredictable
Long-term L-dopa related complications
wearing-off phenomenon, end-of-dose deterioration, peak effect dyskinesia phenomenon, dyskinesia or abnormal involuntary movement
Motor complications
Wearing off response/motor fluctuation, peak-effect dyskinesia or dystonia, delayed onset of medication effect after dosing, “off, no on,” “off” period dystonia, unpredictable “off” period, diphasic dyskinesia, beginning-of-dose deterioration, freezing
Management of “wearing-off” or “on-off” response
increase frequency
switch to CR (decrease the frequency but may require an IR dose in the morning)
adjunctive DA agonist
MAOI
COMTi
amantadine
Management of “off, no-on” response
increase dose frequency
take with water
use ODT
in advanced disease, apomorphine SQ
Management of delayed onset
take it on an empty stomach
water
avoid protein
if on CR, can consider switching off CR or add on IR
Management of peak-effect dyskinesia
decrease the dose
increase the frequency
add amantadine
use CR Sinemet
DA agonist
Management of dystonias
take early morning dose
use CR formulation at HS
DA agonist
baclofen
Botox
Management of freezing
Increase dose
try DA agonist
gait modification, physical therapy
Non-motor complications
Psychosis (hallucinations, confusion), anxiety and depression, dementia, sleep disturbances, somnolence, orthostatic hypotension, sweating episodes, sexual dysfunction, constipation, urinary incontinence
Management of depression in PD
Pramipexole, venlafaxine
Management of dementia and cognitive impairment
RIVASTIGMINE, could try donepezil and galantamine
Management of insomnia
Could try melatonin or eszopiclone
Management of excessive daytime somnolence
Could try modafinil
Management of orthostatic hypotension
Could try fludrocortisone, midodrine, droxidopa
Management of sexual dysfunction
Viagra
Management of constipation
Probiotics and fiber
Management of urinary frequency
Could try solifenacin
Management of drooling
Botox, could try glycopyrrolate
Management of psychosis
Evaluate hypoxemia, infection, electrolyte disturbance
Simplify regimen and D/C meds with highest risk:benefit (anticholinergics, taper and D/C amantadine, selegiline, taper and D/C DA agonists, consider decreasing L-dopa and D/C COMT)
Consider atypical APS drugs (quetiapine, clozapine, pimavanserin/Nuplazid)
Nonpharm treatments
Deep brain stimulation, physical therapy and exercise, strength training, adequate fluids and fiber for constipation, occupational therapy and fall precautions
