Chapter 68: Parkinson's Disease Flashcards by Saina Karami

What is Parkinson disease (PD)?

A degenerative neurological disorder

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What part of the brain is primarily affected by Parkinson disease?

Basal ganglia, including the substantia nigra, striatum, and thalamus

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What neurotransmitter is produced by neurons in the substantia nigra?

Dopamine (DA)

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What happens when approximately 80% of dopamine-producing cells are damaged?

Motor symptoms of Parkinson disease appear

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What does TRAP stand for in relation to Parkinson disease symptoms?

Tremor, Rigidity, Akinesia/bradykinesia, Postural instability

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What is a common first noticeable symptom of Parkinson disease?

Tremor, often starting in one hand or foot

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What is meant by ‘resting tremor’ in Parkinson disease?

Tremor appears when the hand is not moving

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True or False: Medications can cause symptoms similar to Parkinson disease.

True

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What is the purpose of the Abnormal Involuntary Movement Scale (AIMS)?

To measure involuntary movements from medications

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List two psychological symptoms that may occur in advanced Parkinson disease.

Depression
Anxiety

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How does Dopamine blocking drugs effect PD?

Worsen

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Which dopamine blocking drugs can worsen PD?

Phenothiazines (e.g., prochlorperazine)
Butyrophenones (haloperidol, droperidol)
1st and 2nd gen antipsychotics
Metoclopramide

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Which antipsychotics have the lowest risk of worsening PD?

Quetiapine

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How does metoclopramide worsen PD?

A renally-cleared drug that can accumulate in older adults

It is important to consider in the treatment of PD.

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What is ‘off time’ in the context of PD?

Periods when symptoms worsen before the next dose of medication is due

Symptoms can include muscle stiffness, slow movements, and difficulty starting movement.

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What is the psychiatric disease with high incidence of in patients with PD?

Depression

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What are the commonly used medications for treating depression in PD?

SSRIs or SNRIs

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What concerns are associated with SSRIs and SNRIs in PD patients?

Tremor or increased risk of serotonin syndrome

These concerns arise when patients take other serotonergic drugs.

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Which type of tricyclic antidepressants are preferred for PD?

Secondary amines

Examples include desipramine and nortriptyline.

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What is another treatment option for depression in PD aside from antidepressants?

Dopamine agonist pramipexole

Pramipexole has reported antidepressant effects.

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What psychiatric condition can occur with advanced PD or due to drug treatment side effects?

Psychosis

This can manifest as hallucinations or delusions.

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Which antipsychotic is preferred for treating psychosis in PD?

Quetiapine

Quetiapine is favored due to a low risk of movement disorders.

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What metabolic complications can quetiapine cause?

Increased cholesterol and blood glucose

These complications are important to monitor.

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What is a key risk associated with clozapine?

High risk of seizures and agranulocytosis

Frequent monitoring of white blood cells is required.

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What is the FDA-approved medication for treating hallucinations and delusions in PD?

Pimavanserin (Nuplazid) ## Footnote It acts as a 5-HT2A/2C receptor inverse agonist.

What can abrupt withdrawal of levodopa or dopamine agonists lead to?

Condition similar to neuroleptic malignant syndrome (NMS) ## Footnote NMS is a life-threatening condition sometimes seen with antipsychotics.

How should levodopa or dopamine agonists be discontinued?

Slowly tapered ## Footnote This approach helps prevent the onset of NMS.

_____ is a prodrug of dopamine.

Levodopa

What is the most effective agent for treating Parkinson's Disease?

Levodopa

What is the role of Carbidopa in Parkinson's Disease treatment?

To prevent the breakdown of levodopa outside of the CNS ## Footnote This helps ensure more levodopa crosses the blood-brain barrier.

What combination product is used with levodopa?

Sinemet ## Footnote Sinemet is a combination of levodopa and carbidopa.

Which drug class may be better tolerated than dopamine agonists for initial treatment in older adults?

Carbidopa/levodopa ## Footnote This combination may be more suitable for older patients.

What are the treatment goals as Parkinson's Disease progresses?

Reducing 'off' periods and limiting dyskinesias (abnormal movement) ## Footnote Achieving these goals often requires multiple drug classes.

What types of inhibitors are used to manage advanced Parkinson's Disease?

COMT inhibitors and MAO-B inhibitors ## Footnote Catechol-o-methyltransferase

What is the function of centrally-acting anticholinergics in Parkinson's Disease treatment?

To reduce acetylcholine activity within the CNS ## Footnote This helps to alleviate motor symptoms, especially in younger patients.

What does the Beers criteria recommend regarding centrally-acting anticholinergics?

To avoid their use in older adults ## Footnote Due to considerable side effects associated with these drugs.

What is Amantadine used for in Parkinson's Disease treatment?

To help with dyskinesias and tremor ## Footnote It can be an option for initial treatment.

What is Droxidopa (Northera) indicated for in Parkinson's Disease patients?

Orthostatic hypotension

What is a primary treatment principle for Parkinson's Disease?

Replace dopamine ## Footnote This can be achieved through various methods, including mimicking or increasing dopamine.

Fill in the blank: A drug that mimics dopamine is called a _______.

[dopamine agonist]

Fill in the blank: ____ is a drug that increases dopamine.

[levodopa +/- COMT inhibitor]

What is the role of levodopa in Parkinson's disease treatment?

Levodopa is a precursor of dopamine

What is the function of carbidopa in the context of levodopa therapy?

Carbidopa inhibits the dopa decarboxylase enzyme, preventing peripheral metabolism of levodopa

What is the starting dose for carbidopa/levodopa IR tablets?

25/100 mg PO TID

What should you not do with the Rytary ER tablet?

Do not crush or chew

What are the contraindications for carbidopa/levodopa?

* Non-selective MAO inhibitors within 14 days * Narrow angle glaucoma

What are common side effects of carbidopa/levodopa?

* Nausea * Dizziness * Orthostasis * Dyskinesias * Hallucinations * Psychosis * Unusual sexual urges * Priapism

What unusual effect can carbidopa/levodopa have on bodily fluids?

Can cause brown, black or dark discoloration of urine, saliva or sweat

What special monitoring is required for carbidopa/levodopa?

Positive Coombs test: discontinue drug (hemolysis risk)

What is the minimum daily dose of carbidopa required?

70-100 mg/day

What should be noted about long-term use of carbidopa/levodopa?

Can lead to fluctuations in response and dyskinesias

What dietary considerations should be made when taking carbidopa/levodopa?

Separate from oral iron and high protein foods

What should be done if carbidopa/levodopa needs to be discontinued?

Must be tapered; do not discontinue abruptly

What do COMT inhibitors do?

Increase the duration of action of levodopa by inhibiting the enzyme catechol-O-methyltransferase (COMT) ## Footnote Prevents peripheral conversion of levodopa

Which medication is an example of a COMT inhibitor?

Entacapone (Comtan)

What is dosage of Entacapone?

200 mg PO with each dose of Carbidopa/levodopa

What may be necessary when adding a COMT inhibitor?

A reduction in levodopa dose of 10-30% ## Footnote This is due to the extended duration of levodopa action

What do dopamine agonists do?

Act similar to dopamine at the dopamine receptor ## Footnote They mimic the action of dopamine in the brain

Pramipexole brand name

Mirapex, Mirapex ER

What are some warnings associated with Pramipexole?

* Somnolence, * orthostasis, * hallucinations, * dyskinesias, * impulse control disorders ## Footnote These side effects can occur with dopamine agonists

What are common side effects of dopamine agonists?

Dizziness, nausea, vomiting, dry mouth, peripheral edema, constipation

What is the brand name of Ropinirole?

Requip XL

What is a key consideration when discontinuing dopamine agonists?

Avoid abrupt discontinuation ## Footnote A slow titration is required to prevent withdrawal symptoms

What should be done before an MRI if using a Rotigotine patch?

Remove the patch ## Footnote Avoid using the same site for at least 14 days

True or False: Bromocriptine is still recommended for use in Parkinson's disease.

False ## Footnote Bromocriptine is no longer recommended

How many time a day Rotigotine patch is used?

once daily

How often can the same application site be used with Rotigotine patch?

Every 14 days

What is the purpose of dopamine agonists in Parkinson's disease?

Used as a 'rescue' movement drug for 'off' periods

What is the route of administration of Apomorphine?

SC injection

What must be done before Apomorphine be started?

Must be started with a test dose in a medical office

What is a contraindication for using Apomorphine?

Do not use with 5-HT3 antagonists (e.g., ondansetron) due to severe hypotension and loss of consciousness

What severe side effects are associated with Apomorphine?

* Severe nausea/vomiting, * hypotension, * yawning, * dyskinesias, * somnolence, * dizziness, * QT prolongation

What medication can be given for emesis prevention with Apomorphine?

Trimethobenzamide (Tigan) 300 mg PO TID

What drug interactions should be noted for Carbidopa/Levodopa (Sinemet)?

Contraindicated with non-selective MAO inhibitors, iron, and protein-rich foods

What is the mechanism of action for Amantadine?

Blocks dopamine reuptake into presynaptic neurons and increases dopamine release from presynaptic fibers.

What is Amantadine primarily used to treat?

Dyskinesias associated with peak-dose of carbidopa/levodopa.

What are the warnings associated with Amantadine?

Somnolence, compulsive behaviors, psychosis.

What side effects are associated with Amantadine?

Dizziness, orthostatic hypotension,

What is a cutaneous reaction that can occur with Amantadine?

Livedo reticularis.

When is the use of Amantadine ER products contraindicated?

eGFR < 15 mL/min/1.73 m2.

What should be avoided while on Amantadine treatment?

Live vaccines.

What is the mechanism of action for selective MAO-B inhibitors?

Block the breakdown of dopamine, increasing dopaminergic activity.

What is the primary use of selective MAO-B inhibitors?

Adjunctive treatment to carbidopa/levodopa.

What are the contraindications for selective MAO-B inhibitors?

Use in combination with other MAO inhibitors, opioids, SNRIs, TCAs.

What are the warnings associated with selective MAO-B inhibitors?

Serotonin syndrome, hypertension, nausea, CNS depression.

True or False: Rasagiline is indicated for monotherapy.

True.

Why Selegiline should not be taken at bedtime?

It has activating effect

What is the MOA of benztropine?

Centrally- acting anticholinergic

Benztropine Brand name

Cogentin (Koh-jen-tin)

Benztropine SE?

1. confusion 2. somnolence 3. blurred vision 4. mydriasis 5. Dry mouth 6. urinary retention 7. constipation

Droxidopa SE?

Syncope falls headache

What type of food should be avoided when taking MAO-B inhibitors?

Foods high in tyramine including aged or matured cheese, air-dried or cured meat, sauerkraut

Chapter 68: Parkinson's Disease Flashcards

(92 cards)