Week 5- Holistic Care of the Parkinson's Disease Patient Flashcards
what is the first line treatment for parkinsons for when motor symptoms affect their life?
• Offer levodopa to people with early Parkinson’s disease whose motor symptoms
affect their quality of life
what is the first line treatment for parkinsons for when motor symptoms are not affect their life?
• Consider a choice of dopamine agonists, levodopa, or monoamine oxidase B
inhibitors for people with early Parkinson’s disease whose motor symptoms do not
affect their quality of life
when should adjuvant therapy be added on for treatment of motor symptoms in parkinsons?
-first line should be optimised first
When?
• When dyskinesia or motor fluctuations develop (including “wearing off” episodes)
What?
• Offer a choice of dopamine agonists, monoamine oxidase B inhibitors, or catecholO-methyl transferase inhibitors as an adjunct to levodopa
• If dyskinesia is not adequately managed by modifying existing therapy, consider
amantadine
what is levodopa? what it helps with? effectiveness
• First line agent
• Dramatically improves motor function
• Palliative treatment – no effect on disease progression
• Effectiveness decreases with time, must escalate dose
• receptor down-regulation
• disease progression
-can increase life expectancy in patient
whare are some unwanted affects for levodopa?
1. Dyskinesia (involuntary movements) • from 2 years (50% of patients by year 5) • face and limbs 2. Fluctuations in Clinical State • “on-off” phenomena • wearing off effect (end of dose deterioration) • freezing • Entacapone (COMT inhibitor) may help 3. Acute Side Effects • Nausea and anorexia • Hypotension • Sleep disturbances including sudden onset of sleep – implications for driving • Psychological effects
what is levodopa always giving with? and why?
Dopadecarboxylase Inhibitors:
• Carbidopa
• Benserazide
- Levodopa is given as a combination product with either carbidopa or benserazide
- These reduce peripheral metabolism of levodopa and improve absorption of levodopa
- Reduce peripheral side effects
- They do not cross the BBB
what can be giving as a dd on therpay?
COMT Inhibitors : • Entacapone • Tolcapone • Entacapone is given as an adjuvant to co-careldopa/co-beneldopa or as a combination product with co-careldopa • Potentiates the effects of levodopa • Helps counteract fluctuations in plasma concentration of levodopa • Add on therapy – not useful alone
how is levodopa administered?dose? prescribing?
• Max of 800mg Levodopa per day
• titrate benefit vs side-effects
• Small doses of Levodopa at increased frequencies to
reduce ‘peaks and troughs’ and dyskinesia
• Proteins inhibit absorption. Wait 30-60 minutes after
medication before eating
• Brand specific prescribing
• Manage underlying issues which may affect absorption
e.g. constipation, drug interactions
• Iron supplements
how are dopamine receptor agonists used?
- Monotherapy (vs L-DOPA to delay starting it)
- reduced (+ increase time to) motor complications (less dyskinesias)
- slightly poorer improvement in motor function
- possibly greater neuro-psychiatric side effects
- can delay introduction of L-DOPA
- Combined with L-DOPA
- reduced “off” time
- improved motor impairment
- reduced L-DOPA dosage
- increased side effects
what can all dopaergic drugs cause?
impulse control disorder
-can be as log as 4-5 years most likely in men and ppl with smoking/alcohol abuse
what action should happen if someone has impulse control disorder?
• Gradually reduce any dopamine agonist. Monitor whether the impulse control disorder improves and
whether the person has any symptoms of dopamine receptor agonist withdrawal
• Offer specialist cognitive behavioural therapy targeted at ICD behaviours if modification of dopaminergic
therapy is not effective
what is amantadine? side effects
-can be used alone or as combination
• MOA not fully understood
• Increases dopamine levels (possibly by increasing dopamine release)
• Mild benefit to symptoms
• Only used as an adjuvant
• Efficacy diminishes within a few months of continuous treatment - slowly withdrawing and
reintroducing the drug may prolong effectiveness
• Side effects:
• Psychological – hallucinations, delusions, paranoia, anxiety, impulse control disorders
• Sleep disturbances
• GI- nausea, vomiting, anorexia, weight loss, dry mouth
• Hypotension
• Palpitations
between levadopa and dopamine receptor agonists and MAO-b INHIBITORS which one will have more complications with SE but most improvement in symptoms and activities of daily living
levodopa
what is the significance of missing a dose?
• Acute akinesia (the inability to initiate movement)
• Unable to communicate and become more physically dependant on others
• Loss of the ability to swallow, which increases the risk of aspiration
• Increased risk of falls, and a higher risk of fractures
• Neuroleptic-like malignant syndrome (very rare) :
• fever, marked rigidity (including respiratory causing hypoventilation), altered
consciousness, leucocytosis and elevated creatine kinase
• It is caused by a sudden, marked reduction in dopamine activity, either from withdrawal of
dopaminergic agents or from blockade of dopamine receptors
• More common in those with more severe PD symptoms or on high doses of levodopa
what is the treatment for non-motor symptoms of parkinsons?
- Mental Health: • Depression, anxiety, and apathy • Dementia and cognitive impairment • Impulse control and psychotic symptoms - Autonomic dysfunction: • Constipation • Orthostatic (postural) hypotension • Dysphagia → weight loss, aspiration pneumonia • Excessive salivation and sweating • Bladder and sexual dysfunction Nausea and vomiting - Pain - Sleep disturbance and daytime sleepiness - Pressure sores
