Chapter: Neuro Conditions - PD/AD/SZ Flashcards
PARKINSON DISEASE
Parkinson
What are the key factors contributing to the development of Parkinson’s disease, and how do they relate to the loss of dopamine-producing neurons in the substantia nigra?
Parkinson’s disease (PD) is a neurological disorder typically diagnosed after age 65, though 15% of cases occur before age 50. It arises from the death or impairment of neurons in the substantia nigra, a brain region. The exact cause of neuronal death is not fully understood but is thought to involve multiple factors. These neurons produce dopamine, a neurotransmitter crucial for smooth muscle function and movement coordination. Motor symptoms manifest when approximately 80% of dopamine-producing cells are damaged.
Parkinson
What are the s/sx of PD?
Parkinson
Dopamine Blocking Drug That Can Worsen PD
PD
Psych Conditions that are d/t PD? What are some psych conditions that patients with PD may have/ what are some tx options?
Patients with Parkinson’s disease (PD) often experience depression, for which SSRIs or SNRIs are commonly prescribed. However, there are concerns about their potential to exacerbate tremors or increase the risk of serotonin syndrome, especially when combined with other serotonergic medications. Tricyclic antidepressants, particularly secondary amines like desipramine and nortriptyline, as well as the dopamine agonist pramipexole, are alternative treatment options.
Psychosis can also develop in advanced PD or as a side effect of medication. Quetiapine is preferred for its low risk of movement disorders, although it can lead to metabolic complications such as elevated cholesterol and blood glucose levels. Clozapine, while also effective, carries a higher risk of agranulocytosis, seizures, and other serious adverse effects, necessitating close monitoring of white blood cell counts. Pimavanserin (Nuplazid), an FDA-approved 5HT2A/2C receptor inverse agonist, is specifically indicated to manage hallucinations and delusions in PD, offering a treatment option with a different mechanism.
General Overview: What are the key medication options for managing Parkinson’s disease, and how do they differ in their effectiveness, side effects, and suitability for various patient demographics, such as age groups?
Medications play a crucial role in improving movement and addressing related issues like psychosis and constipation in Parkinson’s disease (PD). Levodopa, a precursor of dopamine, is highly effective, often combined with carbidopa in products like Sinemet to prevent its peripheral metabolism. Dopamine agonists are preferred initially for younger patients, while catechol-o-methyltransferase (COMT) inhibitors and MAO-B inhibitors are later additions to manage “off” periods and dyskinesias. Tremor-predominant PD in younger patients may be treated with centrally-acting anticholinergics or selective MAO inhibitors, though their use in the elderly is limited due to side effects. Amantadine or selective MAO inhibitors can also be options for tremor management. Additionally, amantadine helps with dyskinesias, while apomorphine addresses severe freezing episodes, albeit with limitations in administration and duration of effect. Droxidopa (Northera) is a newer medication indicated for orthostatic hypotension in PD patients.
PD: Dopamine Replacement Drug & Agonist
Carbidopa/Levodopa: MOA, Brand, Dosing, C/I, SEs, Notes
Carbidopa/ Levodopa (Sinemet): Titrate cautionsly. IR (starting) - 25/100 PO TID; ER (starting) - 50/200 PO BID - ER can be cut in half
- MOA: Levodopa - precursor of dopamine; Carbidopa inhibits dopa decarboxylase enzyme, preventing peripheral metabolism of levodopa
- C/I: The use of Non-selective MAO inhibitors (phenelzine, isocarboxazid) within 14 days, narrow angle glaucoma
- SEs: Nausea, dizziness, orthostasis, dyskinesias, hallucinations, psychosis, can cause brown/ black urine. positive coombs test? D/C drug d/t hemolysis risk, unusual sexual urges, priapism
- Notes: 70-100 mg/day of carbidopa required to inhibit dopa decarboxylase. Long-term use can lead to fluctuations in response and dyskinesia. Do not d/c abruptly.
PD: Dopamine Replacement Drugs & Agonist
COMT Ihibitors: MOA
Increase the duration of action of levodopa; inhibit the enzyme catechol-O-methyltransfer (COMT) to prevent peripheral conversion of levodopa. COMT inhibitors should only be used with levodopa
PD: Dopamine Replacement Drugs & Agonist
COMT Ihibitors: List the drugs, SEs
Entacapone (Comtan) - 200mg with each dose of carbidopa/levo; Opicapone - 50mg ; Tolcapone
.
SEs - same as levodopa because it’s just extending it’s duration
Dopamine Replacement Drugs & Agonist
Dopamine Agonist: Acts similar to dopamine; List the drugs/ brand, warning, Notes, SEs
- Drug/brands: Pramipexole (Mirapex); Ropinirole (Requip)
- Warning: Somnolence (including sudden daytime sleep attacks), orthostasis, hallucinations, dyskinesias
- SEs: Dizziness, nausea, vomiting, dry mouth, peripheral edema, constipation
- Note: Do not d/c abruptly
Dopamine Replacement Drugs & Agonist
Dopamine Agonist: Used as “rescue” movement drug for “off” periods - Apomorphoine - C/I, SEs, Notes
- C/I: Do not use with 5HT-3 antagonists d/t severe hypotension and loss of consciousness
- SE: severe N/V, hypotension
- Notes: A test dose must be done in a medical office, For emesis prevention: give trimethobenzamide
Other Drug for Parkinson
Amantadine: MOA, Warning, SEs
- MOA: : Blocks dopamine reuptake into presynaptic neurons and increases dopamine release from presynaptic fibers. Primarily used to
treat dyskinesias associated with peak-dose of carbidopa/levodopa.
- Warnings: Somnolence, psychosis
- SEs: Dizziness, orthostatic hypotension, cutaneous reaction (livedo reticularis)
Other Drug for Parkinson
Selective MAO-B Inhibitors: MOA, Drug/brand, C/I, Warning
- MOA: Blocks the breakdown of dopamine which increases dopaminergic activity. Primarily used as a adjunctive treatment to carbidopa/levodopa; rasailine has an indication for monotherapy
- Drug/brand: Selegiline, Rasagiline, Safinamide
- C/I: Do not use in combo with other MAO inhibitors (including linezolid), opioids, SNRIs, severe hepatic impairment
- Warning: Serotonin syndrome, hypertension
Other Drug for Parkinson
Name the class/ drug names
- Centerally- Acting anticholinergics: Benztropine
- Adenosine Receptor Antagonist: Istradefylline
- Alpha/beta agoint: Droxidopa
ALZHEIMER’S DISEASE
ALZHEIMER’S DISEASE SYMPTOMS
- Memory loss, getting lost
- Difficulty communicating , repeating words and information
- Inability to learn or remember new information
- Difficulty with planning and organizing
- Poor coordination and motor function
- Personality changes
- Inappropriate behavior
- Paranoia, agitation, hallucinations
What are the key features and diagnostic challenges associated with different types of dementia, and how does early diagnosis impact treatment and planning for individuals affected by progressive forms such as Alzheimer’s disease?
Different types of dementia exist, such as Alzheimer’s -disease, vascular dementia, and Lewy body dementia, each characterized by distinct clinical features. Alzheimer’s is the most prevalent form and has modestly effective treatment options. Its pathophysiology involves neuritic plaques, tangles in brain tissue disrupting neuron signaling, and altered neurotransmitters like decreased acetylcholine.
.
A definitive diagnosis of dementia type typically requires post-mortem autopsy, though researchers are developing early detection markers. Early diagnosis, crucial for progressive dementias like Alzheimer’s, allows time for future planning while the individual can still engage in decision-making. Initial screening aims to rule out reversible causes like vitamin B12 deficiency, depression, or infection. Memory impairment may also be caused or worsened by certain medications like analgesics or benzodiazepines
List of drugs that can worsen dementia
Alzheimer’s Disease
Screen tools used for dementia: list the general
Mini-Mental State Exam (MMSE), Montreal Cognitive Assessment (MoCA) and DSM-5 criteria
.
Functional abilities can be assessed using the Alzheimer’s Disease Cooperative Study - Activities of Daily Living (ADCSADL) tool.
AD
Screening Tool: Mini-Mental State Exam
Mini-Mental State Exam (MMSE, max score is 30, score < 24 indicates a memory disorder)
AD
Screening Tool: MoCA Exam
– 18-25 = mild cognitive impairment, – 10-17= moderate cognitive impairment and – less than 10= severe cognitive impairment.
AD
ANTICHOLINERGICS & MEMORY IMPAIRMENT
Centrally-acting anticholinergics, like oxybutynin for incontinence and diphenhydramine for allergies or insomnia, are used to manage various conditions, including dystonic reactions. However, they can lead to acute cognitive impairment and, in some cases, psychosis and hallucinations, particularly in elderly individuals. These effects depend on factors such as baseline cognitive function, drug sensitivity, clearance, and potential drug interactions. Due to these risks, the Beers Criteria, which guide appropriate medication use in the elderly, strongly advise against the use of centrally-acting anticholinergics in this population.
AD
Supplements with possible benefit for Alzheimer’s Dementia include:
Vitamin E and Ginko… however both increase risk of bleed!
Drug Treatment Overview for AD
- Acetylcholinesterase inhibitors like donepezil are the primary treatment for dementia.
- They can be used alone or in combination with memantine in advanced stages.
- Improvement with these drugs is typically modest, but they can slow down disease progression.
- Monitoring for both improvement and side effects is crucial.
- Some patients may not experience noticeable improvement and could suffer from side effects like nausea or dizziness.
- Discontinuation of medication may be necessary if there’s no improvement or if side effects are intolerable.
- Timing of administration can help minimize adverse effects, with donepezil often taken at bedtime.
- Memantine is approved for moderate-to-severe disease and can be used alone or with donepezil, such as in the combination Namzaric.
- Antidepressants like sertraline or citalopram can address associated depression and anxiety.
- Antipsychotics, while sometimes used off-label for delusions and agitation, pose an increased risk of death in elderly patients.
ALZHEIMER’S DISEASE DRUGS
Acetylcholinesterase inhibitors: MOA and the drugs/ general doses, SEs, DDI
- MOA: Inhibits centrally-active acetylcholinesterase; the enzyme responsible for the breakdown/ hydrolysis of acetylcholine; that causes an increase in acetylcholine
- Drug:
1. Donepezil (Aricept): PO 5mg QHS ; patch is changed weekly tho
2. Rivastigmine (Exelon - patch and capsule); patch is changed daily!
- SEs: Nausea, Diarrhea, low HR,
- DDI: Use cuation with other drugs that lower heart rate (eg: beta-blockers, diltiazem, verapamil, digoxin) and with drugs that cause dizziness (e.g., antipsychotics, alphablockers, skeletal muscle relaxants, hypnotics, opioids); Drugs that have anticholinergic effects can reduce the efficacy of acetylcholinesterase inhibitors.
ALZHEIMER’S DISEASE DRUGS
Memantine: MOA, brand, warning, SEs, Notes
- MOA: Blocks NMDA (N-Methyl-D-Aspartate) receptors, which inhibits glutamate (an excitatory NT) from binding and decrease abnormal neuron activation
- Memantine (Namenda): IR start with 5mg po; ER start with 7mg po
- Warning: caution with drugs/conditions that increases urine pH …because this decreses the clearance of drug
- SEs: dizziness, confusion, HA
- Notes: ER capsules - do not crush or chew; Capsules can be opened and sprinkled on applesauce
Key Drugs that can lower SZ Threshold
Acute Seizure Management: Status Epilepticus Treatment
Epilipsy/ SZ
Diazepam Rectal Gel (Diastat AcuDial): Dispensing and how to use it?
Antiepileptic Drugs (AED) MOA/ Description in detail how it prevents
Board Spectrum Antiepileptic Drugs
Lamotrigine: brand, dosing, BW, Warning, SEs, Notes, DDI
Lamotrigine (Lamictal)
- Dosing: Inital - weeks 1 and 2: 25mg QD, then 50 mg week 3 and 4…Maintenance Dose: IR 225-375mg QD and XR is 300-400mg QD
- BW: Serious skin reactions, including SJS/TEN
- Warning: Risk of aseptic meningitis, blood dyscrasias, multiorgan hypersensitivity (DRESS) reactions, serious rare immune system reaction
- SEs: alopecia (use supplement selenium and zinc); N/V, rash, tremors
- DDI: In picture!
Board Spectrum Antiepileptic Drugs
Lamictal Starter Kits By Color
Phenytoin/ Fosphenytoin Administration tips
Some AEDs have family members, with similar side effects and safety considerations.
Adjusting Phenytoin Doses: Phenytoin correction - A patient has a total phenytoin level of 13 mcg/ml and recent labs as follows: SCr 1.1 mg/dL, albumin 3.1 g/dl. What is the corrected
phenytoin level (round to the nearest TENTH)?
Antiepil Drugs: List the Selected AEDs with enzyme induction or inhibition
