Treatment of Parkinson's Disease Flashcards
What is used to stage parkinson’s disease?
Hoehn and Yahr staging
Stage 0
No clinical signs or symptoms
Stage 1
One-sided involvement
Stage 2
Bilateral involvement
Stage 3
Bilateral involvement with mild postural abnormalities or history of poor balance and falls
Stage 4
Bilateral involvement with postural instability
Tremor is eclipsed by advancing bradykinesia and rigidity
Stage 5
Severe, advanced
Cannot stand or walk
Cognitive impairment
GI motility is affected
Primary Symptoms
Bradykinesia
Postural abnormalities
Tremor
Muscle rigidity
Functional Scales for Evaluation
ADL and IADLs
Gait and balance assessment
Tinetti
- Gait is observed through 10 foot walk (swinging, step pattern, etc)
- Balance is score through a series of commands (sit/stand, etc)
Movement Disorder Assessment
AIMS- can also be used for drug-induced PD side effects
Cognitive, Mood and Behavior Assessment
GDS, Cornell, Neuropschiatry inventory
Overall PD assessment
UPDRS (unified PD risk scale)
- GOLD standard
Selegiline use, dose, class, titration
Neuroprotective and prevent early symptoms MOAB inhibitor 5 mg BID (RR, disintegrating tablets, patch) Tablet is titrated after 6 weeks
Selegiline side effects, CI, precautions, drug/food interactions
All CI with meperidine, methadone and MAOI
Patch and tablet: muscle relaxants (end in zaprine)
Patch: antidepressants, decongestants, tyramine food
SE: hypertensive crisis
Selegiline Monitoring
PD symptoms
BP
Mood
Rasagiline use, dose, class, titration
Prevention
MAOi
Mono (1 mg QD) or adjunct (0.5 mg QD)
No real titration
Rasagiline CI, precautions, side effects, drug/food interactions
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
Rasagiline Monitoring
Parkinson’s symptoms
BP
Skin
Alpha tocopherol dosing and MOA
Vitamin E
1000 IU BID
Antioxidant - decrease ROS on DA neurons
DATATOP Results
Selegiline is not neuroprotective, but it does allow delay in levodopa therapy (good for early symptoms)
Vitamin E had no effect
Early Treatment: Monotherapy Options
- MAOB inhibitors (selegiline/rasagiline)
- Dopamine replacement (levodopa/carbidopa)
- DA agonists (ropinerole, pramipexole, rotigotine patch)
Minimum Daily Dose of Carbidopa
75 mg
Levodopa/Carbidopa
Sinemet or Sinemet CR - extended release
Daily dose of Levodopa A) 300-400 B) 500-600 C) 700-800 D) 900-1000
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
Sinemet dose, titration
25/100 BID or TID with 4 hours between CR doses
Max 200/2000 mg/day
Sinemet CI, precautions and drug/food interaction
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***
Sinement SE
Orhtostatic hypotension, arrhythmias, anxiety, confusion, N/V, blurred vision
Sinemet Monitoring
PD symptoms
BP
Mental
Sleep (insomnia or vivid dreams)
Pramipexole brand, dose, titration
Mirapex
0.125 mg TID
Up to 0.5 mg TID
Titrate Qweekly
Ropinerole brand, dose, titration
Requip
0.25 mg TID
Up 0.25 mg TID
Titrate Qweekly
Rotigotine Patch brand, dose, titration
Neupro
2 mg transdermally Q24H
Up 2 mg/24 hr Qweekly
Max of 6 mg/24H
Dopamine Agonist CI, precautions, AD, drug/food interactions
CI: hypersensitivity
SE: BP fluctuations, arrhythmias, dizziness, sedation, hallucinations
Interactions: metoclopramide, haldol, reserpine, methyldopa, birthcontrol and smoking
Dopamine Agonists Monitoring
PK symptoms
BP
Mental
Sleep/wake
Anticholinergic Drugs
Diphenhydramine
Benztropine
Trihexyphenidyl
Anticholinergic Drugs Use and SE
Tremor only usually in young patients
SE: dry mouth, blurred vision, constipation, sedation and cognitive impairment
TREAT SYMPTOMS NOT THE DISEASE
Diphenhydramine Brand
Benadryl
Benztropine Brand
Cogentin
Trihexyphenidyl Brand
Artane
Amantadine brand class, use, side effects
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
DA replacement + Selegiline or Rasagiline
Selegiline: extends the interval of levodopa and can actually lead to a 25% reduction in dose
Rasagiline: gives an extra hour of “on” time
DA replacement + DA agonists
DA agonists improve the response to levodopa and decrease “wearing off” and “freezing” (motor complications)
DA replacement + DA agonist + COMT inhibitor
COMT- Extends the duration of levodopa and can reduce the dose so good for motor complications
COMT drugs
Entacapone
Tolcapone
Entacapone brand, dose, titration
Comtam
200 mg with each levodopa dose
Up to 1600 mg/day
Tolcapone brand, dose, titration, special monitoring
Tasmar
100 mg TID
Up to 400 mg TID
LFTs: Baseline, Q2wks for first year, Q4wks, for next 6 months, and then Q8wks
Entacapone CI, precautions, SE and drug/food interactions
CI: Hypersensitivity
SE: dyskinesia, hallucination and hyperactivity
Drugs: Ampicillin, Apomorphine, Erythromycin, Methyldopa, NE, RIfampin, Venlafaxine
Tolcapone CI, precautions, SE and drug/food interactions
CI: Rhabdomyolysis and hepatic disease
SE: confusion, dyskinesia, hallucinations, orthostatic hypotension
Drugs: Apomorphine, methyldopa, etc
COMT inhibitor Monitoring
PK symptoms
BP
Mental
Apomorphine MOA/Use, Dose, titration
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
Apomorphine CI, cautions, SE
CI: 5HT antagoniss (ondansetron)
Caution: CV and cerebrovascular disease
SE: HypOtension, angina, MI, priapism, prolong QT
Apomorphine Monitoring
BP at pre-dose, 20, 40 and 60 minutes after dose
Peak Dose Treatment
RR –> CR
or CR –> RR with more frequent doses
Dystonia define and treatment
Twisting at trunk limbs, head or neck
Baclofen
Dyskinesia treatment
Partial DA agonists (terguride)
Delayed onset treatment
Add RR at the beginning of the dosing interval if on CR
Try crushed or liquid
Administer on an epty stomach
Wearing off treatment
Switch to CR or shorten interval
Try selegiline or rasagiline, DA agonists or COMT inhibitors
Freezing treatment
Increase levodopa/carbidopa
Add DA agonists
Add Rasagiline or entacapone
Random fluctuations treatment
DA agonist or if that doesnt cause predictable effects, drug holiday
Drug resistant periods treatment
Increase levodopa/carbidopa
Reassess administration technique
Myoclonus define and treatment
Involuntary jerky movements during sleep
Decrease nightime levodopa/carbidopa
Clonazepam QHS
Ropinerole is approved for RLS
Akathesia Treatment
Antianxiety options (lorazepam or propranolol)
Control confounding variables through
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)
Make your assessments as objective as possible through
Same individual interviews
Standardized assessments
Document of your observation
Periodically reassess and retry, why?
PK is a progressive disease and things change so what didn’t work early could work now
Fall Factors to Modulate
Environmental factors (trips/fall hazards)
Psychoactive meds (antipsychotics, BZD, antidepressants)
Inappropriate meds (anticholinergics, sedative, muscle relaxants)
Orthostatic hypotension
Other disease states
Poor vision
Incontinence
Cognitive impairment
Signs of Alzheimer’s–like symptoms in early stage PD could indicate a different dementia
Dementia with PD can be treated with rivastigmine (exelon)
Interventions for mood and behavioral disturbances
Examine current treatment regimen (dopaminergic regimen = cause?)
Adjunct therapy if ABSOLUTELY necessary (benefit outweigh the risk_
Atypical agents in PD
Quietiapine or clozapine for hallucination or psychosis
Hallmarks of Dementia with Lewy Bodies
Fluctuating cognitive status
Spontaneous parkinsonism
Visual hallucinations
Dementia with Lewy Bodies Treatment
cholinesterase inhibitor or memantine for cognitive
SSRI for mood/behavior
Avoid anticholinergics for tremor and antipsychotics fo hallucination
Traditional PD meds are not effectivs
Drug-induced PD
Antipsychotics Antiemetics CCB Valpric acid Lithium Albuterol Caffeine