Problem 7: Optimizing prescribing dose and ensure appropriate use of ropinirole Flashcards
Summarise the aims and treatment goals for managing Parkinson’s disease
Who is involved in the MDT?
There is no cure for Parkinson’s disease, but it can be managed – and the symptoms of the disease can be relieved or reduced.
Treating Parkinson’s disease is often a “team effort” involving not only your neurologist but also a wide variety of specialists. Your health care team should include:
Neurologists Occupational therapists Physical therapists Counselors Social workers Speech therapists Registered dietitians
The goals of treatment vary for each person, but in most cases, treatment for Parkinson’s disease is designed to:
Maintain overall quality of life Improve mobility and function Reduce rigidity Reduce tremor Reverse slowed movements Improve posture, gait, balance, speech, and writing skills Maintain mental sharpness
Identify the treatment options available for managing Parkinson’s disease
NICE guidelines: First-line treatment
1.3.5 Offer levodopa to people in the early stages of Parkinson’s disease whose motor symptoms impact on their quality of life. [2017]
1.3.6 Consider a choice of dopamine agonists, levodopa or monoamine oxidase B (MAO‑B) inhibitors for people in the early stages of Parkinson’s disease whose motor symptoms do not impact on their quality of life. [2017]
First-line treatment is levodopa for the management of motor symptoms. Then dopamine agonists, MOA-B inhibitors, COMT inhibitors, dopa-decarboxylase inhibitors.
Levodopa, dopamine agonsits, moa-b inhibitors, COMT inhibitors and dopa-decarboxylase inhibitors
Discuss whether initiation with ropinirole is an appropriate choice? Could any other options have been considered
Ropinirole is indicated for the symptomatic treatment of moderate to severe idiopathic Restless Legs Syndrome
Ropinirole is a non-ergoline D2/D3 dopamine agonist which stimulates striatal dopamine receptors.
In Parkinson’s disease, ropinirole has been associated uncommonly with somnolence and episodes of sudden sleep onset (see Section 4.8) however in Restless Legs Syndrome, this phenomenon is very rare. Nevertheless, patients must be informed of this phenomenon and advised to exercise caution while driving or operating machines during treatment with ropinirole. Patients who have experienced somnolence and/or an episode of sudden sleep onset must refrain from driving or operating machines. Furthermore, a reduction of dosage or termination of therapy may be considered.
Patients with major psychotic disorders should not be treated with dopamine agonists unless the potential benefits outweigh the risks.
Adverse reactions to ropinirole in PD include; hallucinations, confusion, increased libido, syncope, dyskinesia, somnolence, vomiting abdo pain, heartburn.
Clinically review whether the dose is appropriate?
BNF: Initially 750 micrograms daily in 3 divided doses, then increased in steps of 750 micrograms daily, dose to be increased at weekly intervals, increased to 3 mg daily in 3 divided doses, then increased in steps of 1.5–3 mg daily, adjusted according to response
Dose increased by one tablet (250mcg) each week isn’t quick enough titration upwards??
Discuss any unusual side effects associated with using ropinirole and the reason why these may occur
Common side effects: Abdominal pain; confusion; constipation; dizziness; drowsiness; dyskinesia; dyspepsia; fatigue; gastro-oesophageal reflux disease; hallucinations; hypotension; nausea; nervousness; peripheral oedema; sudden onset of sleep; syncope; vomiting.
Excessive daytime sleepiness and sudden onset of sleep can occur with dopamine-receptor agonists.
Paradoxical Restless Legs Syndrome.
Unusual side effects:
Impulse control disorders - gambling, binge eating, hyper-sexuality…the pharmacological
effects of dopamine-receptor agonists. Mr and Mrs Li’s should be warned about these potential
side effects.
Consider whether three times a day dosing is potentially an adherence issue? Would reminder strategies be appropriate?
Likely to be an issue, Mr Li’s cognitive function will continue to deteriorate due to the neurodegenerative nature of PD. Reminder strategies could be employed to help Mrs Li - still a large amount of information, different drugs and precise timing of doses needed.
MCA = multi-compartment compliance aids integrated into practice; but is not a go to option and alternative interventions should be considered too. (Not all medication is appropriate for MCA).
A patient-centred approach to identifying the best intervention must be through a sustainable and
robust individual assessment of both the level of care required by the individual, the reasons for
both intentional and non-intentional non-adherence and the most suitable solution.
- OP and re-ablement of patients at top priority
- Carer training to provide medications from OP
- Assessment to identify the best intervention; MUR included
- MCA intervention of choice - timing of medications paramount importance.
Alternative options:
There are many ways in which patients can be helped to take their medicines safely, or carers
supported to administer medicines correctly. Interventions include, medication review to reduce
inappropriate polypharmacy and simplifying regimen which is particularly important as the number
of prescribed medicines has been shown to be a powerful predictor of non-adherence,18
patient
counselling to improve understanding of medicines-use, the use of reminder charts (as a memory
aid), the use of medicines administration record (MAR) charts, labels with pictograms, large print
labels, information sheets, reminder alarms, IT solutions and new technology such as phone apps
and telemedicine. All of these interventions have a place in ensuring patients take or receive the
correct medicines at the right time. The use of an MCA is just one additional intervention in a range
of intervention options
Explain if any actions are needed in regards to Mr Li driving a motor vehicle
At the time of diagnosis, and if there is a change in their clinical condition, advise any person who drives to inform the Driver and Vehicle Licensing Agency (DVLA) and their car insurer. See the section on Advice about driving for more information.
The Driver and Vehicle Licensing Agency (DVLA) states that:
For Group 1 entitlement (car or motorcycle) — licence will be refused or revoked if the condition is disabling and/or there is clinically significant variability in motor function. If driving would not be impaired, can be considered for licensing subject to satisfactory reports. Licence may be issued subject to regular review.
For Group 2 entitlement (lorry or bus) — licence will be refused or revoked if the condition is disabling and/or there is clinically significant variability in motor function. If driving would not be impaired, can be considered for licensing subject to satisfactory assessment. Licence may be issued subject to annual review.
Describe what counselling you would give with this prescription. What are the potential barriers to understanding and how this might be resolved?
FINISH
How is PD diagnosed?
The diagnosis of PD during life is based upon its distinctive clinical features discerned from the history and neurologic examination. At a minimum, bradykinesia plus either tremor or rigidity must be present in order to consider the diagnosis of PD [1,2]. In addition, an unequivocal, beneficial response to dopaminergic therapy is an important supportive feature of the diagnosis
What are the common non-motor complications with PD?
Mental health conditions : Depression, anxiety, and apathy. Dementia and cognitive impairment. Impulse control disorders and psychosis. Autonomic dysfunction : Constipation. Postural hypotension. Dysphagia and weight loss. Excessive salivation and sweating. Bladder and sexual problems. Other complications : Nausea and vomiting. Pain. Sleep disturbance and daytime hypersomnolence. Aspiration pneumonia. Pressure sores.
What is the mode of action of levodopa?
Levodopa (eg: co-beneldopa and co-careldopa):
Mode of action:
a. levodopa is a precursor of dopamine which will be converted to dopamine in the brain.
b. Dopamine is a chemical messenger which is used to transmit messages between the parts of
the brain and nerves that control movement.
c. Levodopa is usually taken together with benserazide (co-beneldopa) and carbidopa
(co-careldopa) which are peripheral DOPA decarboxylase inhibitor which helps to stop
levodopa to be converted into dopamine prematurely in the bloodstream before entering the
brain. This allow more levodopa enters the brain.
d. With this combination, smaller dose of levodopa is needed to treat the symptoms and thus
reduce the side effects of levodopa such as nausea and vomiting, tiredness, dizziness.
What is the mode of action of dopamine agonists (such as ropinirole?
Dopamine agonist (eg: Ropinirole)
a. Mode of action: substitute for dopamine in brain to stimulate the nerve cells.
b. Benefits: if used together with levodopa, you will take a lower dose of levodopa and thus
reduce the risk of experiencing dyskinesia.
c. Given less frequently compared to levodopa
d. Possible side effects:
i. Nausea or vomiting
ii. Tiredness and sleep
iii. Dizziness
iv. May also cause hallucination and confusion
v. Compulsive behaviors (such as uncontrolled shopping, gambling, eating, and sexual
urges)
What is the mode of action of MOA-B inhibitors?
Monoamine oxidase-B inhibitors (eg: Rasagiline, Selegiline)
Mode of action:
a. Monoamine Oxidase B (MAO-B) is an enzyme that breaks down dopamine in the brain.
b. MAO-B inhibitor blocks MAO-B enzyme which then increase the level of dopamine, and helps
to relieve the symptoms of PD.
What is the mode of action of COMT inhibitors?
COMT inhibitors (eg: Tolcapone, Entacapone)
a. Prevent levodopa from being broken down by enzyme COMT. Usually prescribed for people
in later stage of PD.
b. Possible side effects:
i. May exaggerate some levodopa-related side effects especially dyskinesia
ii. Confusion
iii. Hallucinations
iv. Discoloration of urine (reddish brown or rust-colored)
v. Diarrhea
Why is timing of PD medication so important?
Parkinson’s patient will experience switch on-off symptoms :
• Switched on – when the treatment is effective in controlling the
symptoms because they have taken their medication
• Off-period – may be the end of their medication time and may due
to their next dose of medication
their ability to manage their symptoms may be lost.
