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PR3136 > Treatment of Parkinson's Disease ll > Flashcards

Treatment of Parkinson's Disease ll Flashcards

1
Q

Anticholinergics

A
  • limited use in PD
  • primarily used to control tremors
  • CNS acting
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2
Q

Anticholinergics example

A
  1. Trihexyphenidyl
  2. Benztropine
    - longer acting
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3
Q

Anticholinergic side effects (4)

A
  1. Dry mouth
  2. Constipation
  3. Blurred vision
  4. Sedation
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4
Q

Glutamate activity on NMDA receptors

A
  • associated with neurotoxicity (glutamate)
  • activates NMDA receptors which activates processes that encourage cell death
  • increase glutamatergic activity linked to
    ~ development of and maintenance of levodopa-induced dyskinesias
    Hence, NMDA antagonists inhibit glutamate activity
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5
Q

NMDA antagonists examples (2)

A
  1. Amantadine
  2. Memantine
    - no good evidence on use for levodopa-induced dyskinesias (not recommended for clinical use)
    - can use for mild-moderate alzheimer’s disease
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6
Q

Amantadine MOA

A
  1. Upregulates D2 receptors and increase D2 receptors sensitivity
  2. NMDA antagonists
  3. Anticholinergic

Unknown primary MOA

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7
Q

NMDA antagonists features (3)

A
  • renal excretion
  • can be stimulating (2nd dose in afternoon, not at night)
  • avoid concurrent use with memantine (overstimulation)
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8
Q

NMDA antagonists place in therapy (2)

A
  1. Adjunctive to levodopa
  2. Manage levodopa-induced dyskinesia
    - if prescribed tgt with levodopa, can tell patient on levodopa for at least 3-5 years resulting in dyskinesia
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9
Q

ADR of NMDA antagonists (6)

A
  1. N/V
  2. Light-headedness
  3. Insomnia cos stimulating
  4. Confusion
  5. Hallucinations
  6. Livedo reticularis
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10
Q

Alternative/complementary medicines for PD (8)

A
  1. Co-enzyme Q10
  2. Creatine
  3. Vit E
  4. Glutathione
  5. Riboflavin
  6. Lipoic acid
  7. Acetyl carnitine
  8. Curcumin

However, studies have :
- inconclusive results
or
- they show safety but lack efficacy

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11
Q

Parkinsonism types

A
  1. Vascular parkinsonism

2. Drug-induced parkinsonism

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12
Q

Vascular parkinsonism

A
  • many subtypes but all display signs and symptoms of PD

- due to vasculature in brain

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13
Q

Vascular parkinsonism symptoms (6)

A
  1. Bilateral
  2. No resting tremors
  3. Stepwise in progression
    - increase insult to brain, deterioration progress
  4. Vascular risk factors present
  5. Increasing age is a risk factor
    - VPD patients are older than those with PD
  6. Not caused by infarct/lesions in basal ganglia
    - other parts of the brain
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14
Q

Treatment for PD = Treatment for VPD?

A

No. Treatment for PD is ineffective for VPD

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15
Q

iPD vs DIP (6)

A

DIP

  1. symmetrical
  2. acute or subacute onset
  3. may or may not be reversible
  4. poor response to levodopa
  5. common in females
  6. uncommon for freezing

iPD

  1. asymmetrical
  2. chronic onset
  3. not reversible, progressive
  4. marked response to levodopa
  5. common in males
  6. common for freezing
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16
Q

DIP

A

Drug-induced parkinsonism

  • may unmask existing PD (bring forward PD symptoms earlier)
  • course is variable (3months onset)
  • not always reversible
  • prevention is the best treatment
17
Q

DIP treatment (3)

A
  • withdrawal of the offending drug usually leads to improvements in symptoms in 80% of patients in 8 weeks
  • anticholinergics
  • amantadine
18
Q

DIP offending drugs (4)

A
  1. Antipsychotics
    - higher dose for atypicals antipsychotics
  2. Dopamine antagonists
  3. Antidepressants
    - SSRI
  4. Levothyroxine
19
Q

PHS

A

Parkinson Hyperpyrexia Syndrome (PHS)

20
Q

PHS causes

A
  1. Changes in dopaminergic treatment
  2. Provoked by trauma, surgery, & pulmonary, GI and urinary tract infections
  3. No apparent trigger
21
Q

PHS management (5)

A

If cause is due to reduction in dopaminergic medications,

  1. reinstate previous treatment
  2. increase dose of levodopa gradually
  3. Rotigotine patch or amantadine injections if cannot PO
  4. dantrolene
  5. bromocriptine (ergot derivative dopamine agonist)
22
Q

Severe PHS

A
  • no response to dopaminergic rescue medications
  • symptoms deteriorate rapidly
  • progressively more rigid and immobile
23
Q

Systemic complications of PHS (4)

A
  1. Reduce consciousness leading to aspiration pneumonia
  2. Rhabdomyolysis leading to acute renal failure
  3. Immobility leading to DVT and PE
  4. DIVC (disseminated intravascular coagulation)
24
Q

PD patients in acute care require what inputs?

A
  • require inputs from a range of HCP because the impact of PD is very wide
25
Q

Professionals involved in care of PD patients (8)

A
  1. Doctors
  2. Nurses
  3. Pharmacists
  4. Physiotherapists
    - strengthening exercise so patients do not lose their muscle function and gait
  5. Occupational therapists
    - maintain independence in ADL
    - remain safe at work
  6. Nutritionists
    - maintain balance diet to reduce muscle loss
  7. Speech therapists
    - project voice to communicate
    - proper swallowing
  8. Medical social worker
    - social support
26
Q

Why are PD patients admitted to hospitals

A
  1. Admitted with parkinsonian features but without known PD (not diagnosed until admission)
  2. Known PD but admitted for unrelated problem
  3. Known PD and admitted for specific complications of PD
27
Q
  1. Admitted with parkinsonian features but without known PD (not diagnosed until admission)
A
  • differential diagnosis : DIP, essential tremors
  • accurate diagnosis is impt but difficult due to concurrent illness
  • specialist advice recommended
28
Q
  1. Known PD but admitted for unrelated problem
A
  • most patients not admitted to neurological or geriatric unit
  • need to review meds (avoid anti-dopaminergics & anticholinergics)
  • screen for possible related problems
  • arrange for specialist input
29
Q
  1. Known PD and admitted for specific complications of PD
A

Complications of PD

  • aspiration pneumonia
  • dopamine agonist withdrawal
  • psychosis
  • dyskinesia
30
Q

Medication review (6)

A
  1. Correct preparation?
    - sustained release or immediate release
    - Madopar vs Madopar HBS vs Madopar dispersible
  2. Correct ratio?
    - sinemet 1:4 and 1:10
  3. Can patient swallow the pills whole?
    - Sinemet SR/CR cannot crush
    - Madopar HBS must be swallowed whole
  4. DDI
    - dopamine antagonist
    - anti-emetics (prochlorperazine)
    - SSRI
  5. Comorbidities
    - depression (SSRI)
    - BPH use alpha blockers (worsens hypotension)
  6. Individual specific time of administration
31
Q

ISMP’s recommendations (14)

A
  1. Expedite reconciliation of orders
  2. Allow recreation of administration schedules
  3. Avoid non-formulary delays
  4. Know the symptoms
  5. Avoid contraindicated drugs
  6. Build alerts
  7. Neurology consultation
  8. Manage NBS
  9. Do not abruptly discontinue meds (PHS)
  10. Promote swallowing
  11. Optimal surgery time
  12. Focused education (of staff)
  13. Patient education
  14. Report ADR

PR3136 (19 decks)

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