Movement disorders Flashcards
(25 cards)
How often should patients with Parkinson’s be reviewed?
Every 6-12 months
Domperidone MHRA
Not indicated for those under 12 years or under 35kg
1st line for Parkinsons patients whose motor symptoms affect their quality of life
Levodopa + Carbidopa/Benserazide
Parkinsons patients whose motor symptoms do not affect their quality of life
Can be given levodopa, non-ergot-derived dopamine-receptor agonists (e.g. pramipexole, ropinirole, rotigotine) or monoamine-oxidase B inhibitors (e.g. rasagiline or selegiline)
Dopamine receptor agonists
Non-ergot-derived: pramipexole, ropinirole, rotigotine
Complications with levodopa treatment
Motor complications- response fluctuations and dyskinesia
What are response fluctuations in Parkinsons?
Large variations in motor performance- normal function during ‘on’ period and weakness and restricted mobility during the ‘off’ period.
Levodopa vs dopamine receptor agonists
Levodopa gives more noticeable motor improvements but more likely to experience motor compliacations
Dopamine receptor agonists are more likely to cause excessive sleepiness, hallucinations and impulse control disorders.
If patients develop dyskinesia or motor fluctuations despite optimal levodopa therapy, what can be given?
A choice of:
non-ergotic dopamine-receptor agonists e.g. pramipexole, ropinirole, rotigotine
monoamine oxidase B inhibitors e.g. rasagiline or selegiline
COMT inhibitors e.g. entacapone or tolcapone
as an adjunct to levodopa
then consider ergot-derived dopamine-receptor agonists or amantidine
Ergot-derived dopamine-receptor agonists
Bromocriptine
Cabergoline
Pergolide
Should only be considered as an adjunct to levodopa if the symptoms aren’t controlled by a non-ergot derived dopamine receptor agonist
Daytime sleepiness with Parkinsons
Modafinil- review every 12 months
Should be advised not to drive and inform DVLA
Nocturnal akinesia with Parkinsons
Levodopa or oral dopamine receptor agonists as first line and rotigotine as second line (if both first line options are ineffective)
Postural hypotension in Parkinsons
First line- midodrine
Alternative- fludrocortisone (unlicensed)
Hallucinations and delusions in Parkinsons
No cognitive impairments- quetiapine
If standard treatment ineffective, clozapine can be given
Which antipsychotics can worsen the motor features of Parkinson’s disease?
Phenothiazines (e.g. chlorpromazine)
Butyrophenones
Rapid eye movement sleep behaviour disorder
Clonazepam or melatonin
Parkinson’s disease dementia
AChE inhibitor- all unlicensed except rivastigmine capsules and liquid for mild-to-moderate dementia for those with Parkinsons
Can consider memantine
Treating advanced Parkinsons disease
Apomorphine hydrochloride as intermittent injections of continuous subcutaneous infusions.
Advised to administer domperidone (starting 2 days before apomorphine and discontinue as soon as possible) to control N&V associated with apomorphine.
Apomorphine + domperidone may cause QT prolongation- recommend cardiac risk assessment and ECG monitoring
Switching between levodopa/dopa-decarboxylase inhibitor preparations
Should discontinue 12 hours before
Switching from modified release levodopa to dispersible co-careldopa
Reduce dose by approx 30%
Amantadine cautions
Confused or hallucinatory states
Congestive heart disease (may exacerbate oedema)
Elderly
Tolerance may develop in Parkinsons
Apomorphine cautions
CV disease History of postural hypotension Neuropsychiatric disorders Pulmonary disease Susceptibility to QT prolongation
Stopping anti-Parkinson meds abruptly
Carries small risk of neuroleptic malignant syndrome
Monitoring for apomorphine
Hepatic Haemopoietic Renal CV function Test initially and every 6 months for haemolytic anaemia and thrombocytopenia if taking concomitant levodopa
