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Neuro Quiz 6 > Treatment of Parkinson's Disease > Flashcards

Treatment of Parkinson's Disease Flashcards

1
Q

What is used to stage parkinson’s disease?

A

Hoehn and Yahr staging

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2
Q

Stage 0

A

No clinical signs or symptoms

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3
Q

Stage 1

A

One-sided involvement

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4
Q

Stage 2

A

Bilateral involvement

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5
Q

Stage 3

A

Bilateral involvement with mild postural abnormalities or history of poor balance and falls

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6
Q

Stage 4

A

Bilateral involvement with postural instability

Tremor is eclipsed by advancing bradykinesia and rigidity

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7
Q

Stage 5

A

Severe, advanced
Cannot stand or walk
Cognitive impairment
GI motility is affected

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8
Q

Primary Symptoms

A

Bradykinesia
Postural abnormalities
Tremor
Muscle rigidity

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9
Q

Functional Scales for Evaluation

A

ADL and IADLs

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10
Q

Gait and balance assessment

A

Tinetti

  • Gait is observed through 10 foot walk (swinging, step pattern, etc)
  • Balance is score through a series of commands (sit/stand, etc)
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11
Q

Movement Disorder Assessment

A

AIMS- can also be used for drug-induced PD side effects

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12
Q

Cognitive, Mood and Behavior Assessment

A

GDS, Cornell, Neuropschiatry inventory

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13
Q

Overall PD assessment

A

UPDRS (unified PD risk scale)

- GOLD standard

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14
Q

Selegiline use, dose, class, titration

A 
Neuroprotective and prevent early symptoms
MOAB inhibitor
5 mg BID
(RR, disintegrating tablets, patch)
Tablet is titrated after 6 weeks
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15
Q

Selegiline side effects, CI, precautions, drug/food interactions

A

All CI with meperidine, methadone and MAOI
Patch and tablet: muscle relaxants (end in zaprine)
Patch: antidepressants, decongestants, tyramine food
SE: hypertensive crisis

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16
Q

Selegiline Monitoring

A

PD symptoms
BP
Mood

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17
Q

Rasagiline use, dose, class, titration

A

Prevention
MAOi
Mono (1 mg QD) or adjunct (0.5 mg QD)
No real titration

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18
Q

Rasagiline CI, precautions, side effects, drug/food interactions

A

CI: muscle relaxants, dextromethorphan, meperidine, methadone, tramadol MAOIs
Caution: antidepressants, melanoma, hepatic disease, 1A2 substrates
SE: orthostatic hypotension, HTN, GI, RASH, headache, vivid dreams
Food: Tyramine

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19
Q

Rasagiline Monitoring

A

Parkinson’s symptoms
BP
Skin

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20
Q

Alpha tocopherol dosing and MOA

A

Vitamin E
1000 IU BID
Antioxidant - decrease ROS on DA neurons

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21
Q

DATATOP Results

A

Selegiline is not neuroprotective, but it does allow delay in levodopa therapy (good for early symptoms)
Vitamin E had no effect

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22
Q

Early Treatment: Monotherapy Options

A
  1. MAOB inhibitors (selegiline/rasagiline)
  2. Dopamine replacement (levodopa/carbidopa)
  3. DA agonists (ropinerole, pramipexole, rotigotine patch)
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23
Q

Minimum Daily Dose of Carbidopa

A

75 mg

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24
Q

Levodopa/Carbidopa

A

Sinemet or Sinemet CR - extended release

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25
Q 
Daily dose of Levodopa 
A) 300-400
B) 500-600
C) 700-800
D) 900-1000
A

Sinemet CR Regimen
A) 50/200 mg 1 tablet BID
B) 50/200 mg 1 tab TID
C) 50/200 mg 4 tablets TID or in combo with 25/100 mg form
D)50/200 mg 5 tablets TID or in combo with 25/100 mg form

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26
Q

Sinemet dose, titration

A

25/100 BID or TID with 4 hours between CR doses

Max 200/2000 mg/day

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27
Q

Sinemet CI, precautions and drug/food interaction

A

CI: narrow angle glaucoma, malignant melanoma, skin conditions
Caution: MI, arrhythmias, asthma, wide angle glaucoma, PUD
Drug: Pheytoin, BZD, TCA, Haldol, methyldopa, antacids, MAOI
Food- PROTEIN***

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28
Q

Sinement SE

A

Orhtostatic hypotension, arrhythmias, anxiety, confusion, N/V, blurred vision

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29
Q

Sinemet Monitoring

A

PD symptoms
BP
Mental
Sleep (insomnia or vivid dreams)

30
Q

Pramipexole brand, dose, titration

A

Mirapex
0.125 mg TID
Up to 0.5 mg TID
Titrate Qweekly

31
Q

Ropinerole brand, dose, titration

A

Requip
0.25 mg TID
Up 0.25 mg TID
Titrate Qweekly

32
Q

Rotigotine Patch brand, dose, titration

A

Neupro
2 mg transdermally Q24H
Up 2 mg/24 hr Qweekly
Max of 6 mg/24H

33
Q

Dopamine Agonist CI, precautions, AD, drug/food interactions

A

CI: hypersensitivity
SE: BP fluctuations, arrhythmias, dizziness, sedation, hallucinations
Interactions: metoclopramide, haldol, reserpine, methyldopa, birthcontrol and smoking

34
Q

Dopamine Agonists Monitoring

A

PK symptoms
BP
Mental
Sleep/wake

35
Q

Anticholinergic Drugs

A

Diphenhydramine
Benztropine
Trihexyphenidyl

36
Q

Anticholinergic Drugs Use and SE

A

Tremor only usually in young patients
SE: dry mouth, blurred vision, constipation, sedation and cognitive impairment
TREAT SYMPTOMS NOT THE DISEASE

37
Q

Diphenhydramine Brand

38
Q

Benztropine Brand

39
Q

Trihexyphenidyl Brand

40
Q

Amantadine brand class, use, side effects

A

Symmetrel
NMDA receptor antagonist
Primarily tremor, mild symptoms
Not in older pts due to renal elimination and CNS effects
SE: dizziness, sedation confusion, vivid dreams, delirium

41
Q

DA replacement + Selegiline or Rasagiline

A

Selegiline: extends the interval of levodopa and can actually lead to a 25% reduction in dose
Rasagiline: gives an extra hour of “on” time

42
Q

DA replacement + DA agonists

A

DA agonists improve the response to levodopa and decrease “wearing off” and “freezing” (motor complications)

43
Q

DA replacement + DA agonist + COMT inhibitor

A

COMT- Extends the duration of levodopa and can reduce the dose so good for motor complications

44
Q

COMT drugs

A

Entacapone

Tolcapone

45
Q

Entacapone brand, dose, titration

A

Comtam
200 mg with each levodopa dose
Up to 1600 mg/day

46
Q

Tolcapone brand, dose, titration, special monitoring

A

Tasmar
100 mg TID
Up to 400 mg TID
LFTs: Baseline, Q2wks for first year, Q4wks, for next 6 months, and then Q8wks

47
Q

Entacapone CI, precautions, SE and drug/food interactions

A

CI: Hypersensitivity
SE: dyskinesia, hallucination and hyperactivity
Drugs: Ampicillin, Apomorphine, Erythromycin, Methyldopa, NE, RIfampin, Venlafaxine

48
Q

Tolcapone CI, precautions, SE and drug/food interactions

A

CI: Rhabdomyolysis and hepatic disease
SE: confusion, dyskinesia, hallucinations, orthostatic hypotension
Drugs: Apomorphine, methyldopa, etc

49
Q

COMT inhibitor Monitoring

A

PK symptoms
BP
Mental

50
Q

Apomorphine MOA/Use, Dose, titration

A

Dopamine agonist!!
SQ to help reduce motor fluctuations and reduce “off” time
TEST DOSE REQUIRED- 0.2 mL SQ test dose and then initial dose of 0.2
MAX of 2 mL
Titration: test dose of 0.4 mL give 0.3 mL dose, test dose 0.3 mL give 0.2 mL

51
Q

Apomorphine CI, cautions, SE

A

CI: 5HT antagoniss (ondansetron)
Caution: CV and cerebrovascular disease
SE: HypOtension, angina, MI, priapism, prolong QT

52
Q

Apomorphine Monitoring

A

BP at pre-dose, 20, 40 and 60 minutes after dose

53
Q

Peak Dose Treatment

A

RR –> CR

or CR –> RR with more frequent doses

54
Q

Dystonia define and treatment

A

Twisting at trunk limbs, head or neck

Baclofen

55
Q

Dyskinesia treatment

A

Partial DA agonists (terguride)

56
Q

Delayed onset treatment

A

Add RR at the beginning of the dosing interval if on CR
Try crushed or liquid
Administer on an epty stomach

57
Q

Wearing off treatment

A

Switch to CR or shorten interval

Try selegiline or rasagiline, DA agonists or COMT inhibitors

58
Q

Freezing treatment

A

Increase levodopa/carbidopa
Add DA agonists
Add Rasagiline or entacapone

59
Q

Random fluctuations treatment

A

DA agonist or if that doesnt cause predictable effects, drug holiday

60
Q

Drug resistant periods treatment

A

Increase levodopa/carbidopa

Reassess administration technique

61
Q

Myoclonus define and treatment

A

Involuntary jerky movements during sleep
Decrease nightime levodopa/carbidopa
Clonazepam QHS
Ropinerole is approved for RLS

62
Q

Akathesia Treatment

A

Antianxiety options (lorazepam or propranolol)

63
Q

Control confounding variables through

A

One change at a time
Be mindful of timeline for changes
Include titration and/or taper of doses
Rule out other meds and factors (diet)

64
Q

Make your assessments as objective as possible through

A

Same individual interviews
Standardized assessments
Document of your observation

65
Q

Periodically reassess and retry, why?

A

PK is a progressive disease and things change so what didn’t work early could work now

66
Q

Fall Factors to Modulate

A

Environmental factors (trips/fall hazards)
Psychoactive meds (antipsychotics, BZD, antidepressants)
Inappropriate meds (anticholinergics, sedative, muscle relaxants)
Orthostatic hypotension
Other disease states
Poor vision
Incontinence

67
Q

Cognitive impairment

A

Signs of Alzheimer’s–like symptoms in early stage PD could indicate a different dementia
Dementia with PD can be treated with rivastigmine (exelon)

68
Q

Interventions for mood and behavioral disturbances

A

Examine current treatment regimen (dopaminergic regimen = cause?)
Adjunct therapy if ABSOLUTELY necessary (benefit outweigh the risk_

69
Q

Atypical agents in PD

A

Quietiapine or clozapine for hallucination or psychosis

70
Q

Hallmarks of Dementia with Lewy Bodies

A

Fluctuating cognitive status
Spontaneous parkinsonism
Visual hallucinations

71
Q

Dementia with Lewy Bodies Treatment

A

cholinesterase inhibitor or memantine for cognitive
SSRI for mood/behavior
Avoid anticholinergics for tremor and antipsychotics fo hallucination
Traditional PD meds are not effectivs

72
Q

Drug-induced PD

A 
Antipsychotics
Antiemetics
CCB
Valpric acid
Lithium 
Albuterol
Caffeine

Neuro Quiz 6 (2 decks)

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