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therapeutics 3 - exam 3 > lecture 43 > Flashcards

lecture 43 Flashcards

campbell - pharmacotherapy of PD (54 cards)

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1
Q

how does PD develop?

A

slow over 5-10 years with an increase in motor symptoms with cognitive symptoms may presenting after several years
life expectancy of 15 years after diagnosis

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2
Q

what are motor symptoms associated with PD?

A

tremor, bradykinesia, rigidity, parkinsonian gait

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3
Q

what are non-motor symptoms associated with PD?

A

anxiety, depression
constipation
dementia
insomnia
orthostatic hypotension
psychosis/delirium
sexual dysfunction

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4
Q

what are the two assessment of PD?

A

Unified Parkinson’s Disease Rating Scale (UPDRS)
clinical assessment (observe motor symptoms and impact on QOL)

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5
Q

what is apart of a UPDRS?

A

standardized rating scale to assess s/sx of PD
scores from 0-4 to assess 42 domains for PD severity
higher = worse symptoms

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6
Q

what are goals of therapy in PD?

A

minimize/manage motor and non-motor symptoms
maintain highest QOL possible
preserve activities of daily living (ADLs)
minimize/manage ADRs

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7
Q

what are non-pharmacologic therapies?

A

exercise/physical therapy
nutritional counseling
occupational therapy
psychotherapy/support groups
speech therapy

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8
Q

what is the first line treatment of PD?

A

rule out drug-induced PD
dopamine precursor
(dopamine agonists)
(MAO-B inhibitor)

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9
Q

what is second line treatment of PD?

A

COMT inhibitors
amantadine

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10
Q

when should DA agonist as initial treatment be avoided?

A

over 70y
hx of ICD
cognitive impairment
excessive daytime sleepiness
hallucinations

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11
Q

what are general initiation terms?

A

initiate with Levodopa
initiate with IR > CR
initiate with lowest effective dose to delay AE or dyskinesia

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12
Q

when is it ok to use a DA agonist as initial treatment?

A

under 60 years
higher risk for dyskinesia

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13
Q

what drugs are preferred due to efficacy with motor symptoms?

A
  1. Levodopa/carbidopa
  2. DA
  3. MAO-B inhibitors
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14
Q

what is an important SE of levodopa?

A

LD motor fluctuations/dyskinesia

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15
Q

what are examples of LD motor fluctations?

A

wearing off
freezing
delayed onset
peak-dose dyskinesia

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16
Q

what does a wearing off LD motor fluctuation look like?

A

before next dosing interval, signs of motor symptoms occur

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17
Q

what does a freezing LD motor fluctuation look like?

A

inability to move due to insufficient or fluctuating DA levels

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18
Q

what does a delayed onset LD motor fluctuation look like?

A

therapeutics benefits delayed

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19
Q

what does a peak-dose dyskinesia LD motor fluctuation look like?

A

involuntary body movement caused by high DA levels

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20
Q

what is the starting dose of levodopa?

A

25/100 mg CD/LD PO TID with meals

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21
Q

what is the maintenance frequency of levodopa?

A

5-6x per day can increase prn

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22
Q

what DA agonists are non-ergot?

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A

pramipexole, ropinirole, rotigotine, apomorphine

23
Q

what DA agonists are ergot?

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A

bromocriptine, cabergoline

24
Q

what DA are first-line for initial PD therapy?

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A

non-ergot (ergot have toxicity)

25
what are the advantages of DA agonists?
fewer motor fluctuations long-acting formulations
26
what drugs are MAO-B inhibitors?
rasagiline selegiline safinamide
27
what are MAO-B inhibitors role in therapy?
first line for mild symptoms second line as adjunct adjunctive for PD depression
28
what are CP associated with MAO-B inhibitors?
risk of serotonin syndrome with drug-drug interactions (serotonergic antidepressants, dextromethorphan, serotonergic opioids)
29
what drugs are COMT inhibitors?
entacapone, opicapone, tolcapone
30
what are COMT inhibitors role in therapy?
in combination to manage symptom fluctuation (wearing off)
31
what are SE of COMT inhibitors?
NV brown/orange urine discoloration (E) hepatotoxicity (T)
32
what is the role of amantadine in therapy?
management of LD motor fluctuations modest effect in controlling motor symptoms, but rarely used as monotherapy due to tremor
33
what are SE of amantadine?
insomnia confusion/hallucinations livedo reticularis
34
what are CP of amatadine?
utility limited due to cognitive SE usually reserved CD/LD peak dose dyskinesias
35
what drugs are anticholinergics used in PD?
benztropine trihexyphenidyl
36
what is the role of anticholinergics in therapy?
management of tremor-dominant symptom in pts under 65 yr
37
what are SE of anticholinergics?
confusion/dementia blurry vision urinary retention dry mouth constipation
38
what are monitoring parameters of PD drugs?
evaluate motor symptoms assess for SE related to pharmacotherapy identify medications which can worsen PD
39
what medications may worsen PD?
dopamine antagonists - antipsychotics, metoclopramide, prochlorperazine, promethazine
40
what is important patient education for PD?
stress importance of adherence and timing of medication administration to patient/caregiver (make rescue plan, multiple formulations/schedule options to personalize care) pros/cons of taking med with food report SE and symptoms to PCP support group and education referral
41
what is the pros about using DA agonist as first line?
once daily dosing formulations better tolerated by younger pts limited motor fluctuations
42
what are pros about using carbidopa/levodopa as initial first-line?
gold standard due to symptomatic benefit cost variety of dosage forms
43
what are pros of using MAO-B inhibitors as initial first line?
generally well tolerated delays onset of motor fluctuations
44
what are cons of using DA agonists as first line?
expensive (esp long acting) less symptomatic benefit compared to CD/LD many AE
45
what are cons of using carbidopa/levodopa as first line?
motor fluctuations dosing frequency (can be over 3x)
46
what are cons of using MAO-B as first line?
least effective first line agent against motor symptoms calls for dietary restrictions and increases risk of serotonin syndrome
47
who should use DA agonists as first line?
under age 60 and higher risk of dyskinesia
48
who should use carbidopa/levodopa as first line?
most
49
who should use MAO-B inhibitors as first-line?
minor symptoms higher risk of motor fluctuations
50
how should wearing off fluctuation be treated?
increase CD/LD dose or frequency add DA agonist, MAO-B, or COMTi use XR CD/LD
51
how should freezing fluctuation be treated?
increase CD/LD dose or frequency add DA agonist (apomorphine) add ODT CD/LD
52
how should delayed onset fluctuation be treated?
take CD/LD on empty stomach ODT CD/LD avoid CR/XR CD/LD
53
how should peak-dose dyskinesia fluctuation be treated?
add amantadine decrease dose of DA or CD/LD
54
what drugs should be avoided in correlation to their non-motor symptom?
benzodiazepines - insomnia/anxiety/depression/dementia anticholinergics - dementia antihistamines - dementia sedatives - dementia psychosis/delirium - haloperidol, olanzapine, paliperidone, risperidone

therapeutics 3 - exam 3 (13 decks)

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