PD Treatment Complications and Management

Question 1

Evaluating patient’s response to L-Dopa: Stage I

Answer 1

patient not aware of variation in effect of an individual dose

Question 2

Evaluating patient’s response to L-Dopa: Stage II

Answer 2

midafternoon loss of benefit requires additional dose in addition to an early AM dose

Question 3

Evaluating patient’s response to L-dopa: Stage III

Answer 3

good response to levodopa, sleep benefit is lost, early-morning akinesia appears

Question 4

Evaluating patient’s response to L-dopa: Stage IV

Answer 4

regular “Wearing off” every 4 or more hours, levodopa response gradually shortens

Question 5

Evaluating patient’s response to L-dopa: Stage V

Answer 5

“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

Question 6

Long-term L-dopa related complications

Answer 6

wearing-off phenomenon, end-of-dose deterioration, peak effect dyskinesia phenomenon, dyskinesia or abnormal involuntary movement

Question 7

Motor complications

Answer 7

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

Question 8

Management of “wearing-off” or “on-off” response

Answer 8

increase frequency
switch to CR (decrease the frequency but may require an IR dose in the morning)
adjunctive DA agonist
MAOI
COMTi
amantadine

Question 9

Management of “off, no-on” response

Answer 9

increase dose frequency
take with water
use ODT
in advanced disease, apomorphine SQ

Question 10

Management of delayed onset

Answer 10

take it on an empty stomach
water
avoid protein
if on CR, can consider switching off CR or add on IR

Question 11

Management of peak-effect dyskinesia

Answer 11

decrease the dose
increase the frequency
add amantadine
use CR Sinemet
DA agonist

Question 12

Management of dystonias

Answer 12

take early morning dose
use CR formulation at HS
DA agonist
baclofen
Botox

Question 13

Management of freezing

Answer 13

Increase dose
try DA agonist
gait modification, physical therapy

Question 14

Non-motor complications

Answer 14

Psychosis (hallucinations, confusion), anxiety and depression, dementia, sleep disturbances, somnolence, orthostatic hypotension, sweating episodes, sexual dysfunction, constipation, urinary incontinence

Question 15

Management of depression in PD

Answer 15

Pramipexole, venlafaxine

Question 16

Management of dementia and cognitive impairment

Answer 16

RIVASTIGMINE, could try donepezil and galantamine

Question 17

Management of insomnia

Answer 17

Could try melatonin or eszopiclone

Question 18

Management of excessive daytime somnolence

Answer 18

Could try modafinil

Question 19

Management of orthostatic hypotension

Answer 19

Could try fludrocortisone, midodrine, droxidopa

Question 20

Management of sexual dysfunction

Answer 20

Viagra

Question 21

Management of constipation

Answer 21

Probiotics and fiber

Question 22

Management of urinary frequency

Answer 22

Could try solifenacin

Question 23

Management of drooling

Answer 23

Botox, could try glycopyrrolate

Question 24

Management of psychosis

Answer 24

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)

Question 25

Nonpharm treatments

Answer 25

Deep brain stimulation, physical therapy and exercise, strength training, adequate fluids and fiber for constipation, occupational therapy and fall precautions