Drugs for Movement Disorders Flashcards
(50 cards)
1
Q
How can rehabilitation be used as a non-pharmacological treatment of PD?
A
- Focus on gait re-education
- Improvement of balance and flexibility
- Enhancement of aerobic capacity and strength
- Improvement of movement initiation
- Augmentation of functional independence
2
Q
What can occupational therapy include in treatment of PD?
A
- Speech and language therapy for those experiencing problems with communicating, swallowing, or saliva
- Strategies to improve the safety and efficacy of swallowing to minimize the risk of aspiration, such as expiratory muscle stress
- Strategies to improve speech and communication, such as attention to effort therapies
3
Q
What does MAO-A metabolize?
A
- Norepinephrine and serotonin
4
Q
What does MAO-B metabolize?
A
- Phenylethylamine and benzylamine
5
Q
What metabolizes dopamine and tryptamine?
A
- Equally by MOA-A and MOA-B
6
Q
What is the MOA of amantadine?
A
- Exact mechanism is unknown
- Direct and indirect effects on dopamine neurons
7
Q
What are the clinical applications of amantadine?
A
- Drug-induced extrapyramidal symptoms
- Adjunctive therapy for dyskinesias
- Monotherapy for patients with mild motor symptoms
8
Q
What are some toxicities of amantadine?
A
- CNS depression
- Impulse control disorders
- Psychosis
- Suicidal ideation and depression
- May cause livedo reticularis –> purplish mottled discoloration of the skin, usually on the legs
9
Q
What is the MOA of selegiline?
A
- Potent, irreversible inhibitor of MAO
10
Q
What are the clinical applications of selegiline?
A
- Adjunct in the management of PD when levodopa/carbidopa use has on-off phenomenon
- Off label use is PD
11
Q
What are some toxicities seen with selegiline?
A
- Antidepressants increased risk of suicidal thoughts and behaviors in pediatric and young adult patients in short term studies
- May cause exacerbation of HTN
- May cause CNS depression
12
Q
What is the MOA of ropinirole?
A
- Non-ergot, has high relative in vitro specificity and full intrinsic activity at D2 and D3 DA receptors
13
Q
What are the clinical applications of ropinirole?
A
- Treatment of PD
- Can be administered in addition to levodopa/carbidopa and/or to treat levodopa on-off phenomenon
- No efficacy in those who levodopa doesn’t work
14
Q
What are some toxicities with ropinirole?
A
- Dyskinesias
- Impulse control disorders/compulsive behaviors
- Increased risk of melanomas
- Orthostatic hypotension
- Psychotic effects
- Somnolence
- N/V, constipation
- Headaches
15
Q
What is the MOA of tolcapone?
A
- Selective and reversible inhibitor of COMT –> a major pathway for levodopa degradation when decarboxylase is blocked by carbidopa
16
Q
What are the clinical applications of tolcapone?
A
Adjunct to levodopa and carbidopa for the treatment of idiopathic PD in patients with motor fluctuations
17
Q
What is a big risk of tolcapone?
A
- Risk of potentially fatal acute fulminant liver failure, only use in PD patients on L-dopa/carbidopa who are experiencing symptom fluctuations and are NOT responding satisfactory to other agents
18
Q
What are some toxicities of tolcapone?
A
- Abnormal thinking/behavioral changes
- CNS depression
- Loss of impulse control
- Orthostatic hypotension
- Exacerbation of preexisting dyskinesia
19
Q
What is the MOA of carbidopa and levodopa?
A
- Immediate precursor to dopamine
- Crosses BBB
- Carbidopa is a peripheral DOPA decarboxylase inhibitor
20
Q
What are the clinical applications of carbidopa and levodopa?
A
- Parkinsonian syndrome
- Restless leg syndrome
21
Q
What are the toxicities of carbidopa and levodopa?
A
- GI effects –> anorexia, N/V
- Postural hypotension
- Hypertension and/or cardiac arrhythmias
- Dyskinesias
- Behavioral effects
- Wearing off and on-off phenomena
22
Q
Why is carbidopa given with levodopa?
A
- A smaller dose of levodopa can be given but still have the same amount reach the brain
- Carbidopa blocks peripheral DOPA decarboxylase
23
Q
What are some device aided therapies for movement disorders?
A
- Deep brain stimulation of the subthalamic nucleus or globus pallidus interna
- Intrajejunal levodopa-carbidopa enteric gel administered through percutaneous gastrostomy
24
Q
What is the on-off phenomenon in PD?
A
- Back and forth switch between mobility and immobility in levodopa treated patients
- Typically occurs as an end-of-dose or “wearing off” worsening of motor function
25
What can help reduce the on-off phenomenon in PD?
- Controlled release form of levodopa
- Shorten the interval between levodopa doses
- Adding a medication --> dopamine agonist, COMT inhibitors, or MAO-B
26
What is the MOA of benztropine?
- Cholinergic antagonist at muscarinic receptors
| - Also blocks histamine receptors
27
What are the clinical applications of benztropine?
- Monotherapy or combo for PD
- Predominantly for tremor and dystonia in younger people
- Should be avoided in elderly and those with cognitive impairment
- Can be helpful in reducing the amount of saliva to treat excessive drooling
28
What are some toxicities of benztropine?
- Anti-cholinergic effects
29
What are the four main drugs class choices for monotherapy of symptomatic PD?
- MAO-B inhibitors
- Amantadine
- Dopamine agonists
- Levodopa
30
What is given to patients with mild symptoms and want little interference with daily function?
- MAO-B inhibitor --> given once daily
| - Amantadine
31
What is given to patients older than 65 with diminished daily function and quality of life?
- DA agonist or levodopa
32
What is given to patients younger than 65 with diminished daily function and quality of life?
- Immediate release levodopa --> more effective for improving motor function and quality of life
33
What can be used to treat sialorrhea in PD?
- Botulinum toxin A injections
34
What can be used to treat orthostatic hypotension in PD
- Midodrine
- Domperidone
- Fludrocortisone
35
What can be used to treat REM sleep behavior disorder in PD?
- Melatonin or clonazepam
36
What can be used to treat depression in PD?
- Start low and go slow
37
What can be used to treat psychosis in PD?
- Quetiapine and clozapine --> standard treatment
| - Maybe rimavanserin
38
What can be used to treat dementia in PD?
- Rivastigmine or donepezil
| - Memantine
39
What is the biggest focus when treating Huntington disease?
- Treat non-motor symptoms like depression, irritability, paranoia, anxiety, or psychosis
40
What are some non-pharmacologic treatments for restless leg syndrome?
- Exercise
- Leg massage
- Applied heat
- Avoidance of aggravating drugs and sleep deprivation
41
What could help symptoms of restless leg syndrome?
- Correction of coexisting iron deficiency anemia
42
What can be given if there is persistent severe restless leg syndrome despite non-pharmacologic therapy?
- Non-ergot dopamine agonists (ropinirole) --> if comorbid depression or obesity/metabolic syndrome
- Alpha-2-delta calcium channel ligand if there are no comorbidities or comorbid pain, anxiety, or insomnia
43
What can be given for restless leg syndrome in pregnancy?
- Often managed with nonpharmacologic strategies, iron supplementation
- Pharmacologic therapies to consider if needed include clonazepam and carbidopa-levodopa
44
What should first be looked at when treating restless leg syndrome?
- Iron stores --> replete iron if <75 ng/mL
45
What is used when treating an intermittent disability due to tremor?
- Propranolol is first line
46
What is used when treating a persistent disability due to tremor?
- Propranolol and primidone are first line
- Gabapentin is second line
- Botulinum toxin is used in drug refractory tremor
47
What is the only drug that seems to have an impact on the survival of ALS?
- Riluzole
48
What are some treatment options for Wilson disease?
- Low copper diet
| - Agents that reduce copper levels --> penicillamine and potassium disulfide
49
What is the MOA of penicillamine?
- Copper chelating agent that is readily excreted by the kidney
50
What does potassium disulfide do?
- Reduces intestinal absorption of copper
