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Flashcards in Parkinson 2 Deck (38):
1

What is the precursor of Dopamine?

Levodopa/Carbidopa/L-dopa

2

  • What is the best tx of a pt who is 65 yrs or older?
  • Is useful if tremor is not controlled by an anticholinergic
  • Most effective drug for symptomatic tx of PD

 

Levodopa / Carbidopa

3

Ultimately all pts w/ PD will require what med?

Levodopa / Carbidopa / l-dopa

4

Why is Carbidopa added to Levodopa?

It prevents the breakdown of Levodopa

5

Carbidopa inhibits peripheral metabolism of Levodopa via ___ ______. 

Dopa decarboxylase

6

Ultimately leads to an increase in the fraction of the dose that reaches the brain.

Role of adding Carbidopa to Levodopa (prevents breakdown of Levodopa)

7

What 2 drugs interact w/ Levodopa/Carbidopa resulting in:

  • diminished doses
  • prolonged action

What would pt experience w/ this interaction?

COMT (peripheral & brain, prevent dopamine degredation)

MAO B inhibitors

Excess dopamine (hallucinations/schizophrenia) and EPS - extra priamital ability

8

Adverse effects of what drug?

  • Drowsiness
  • Dyskinesias
  • **Motor Complications**

Levodopa / Carbidopa

9

MOA of what drug?

  • Blocks the conversion of L-dopa into the inactive form of 3-O-Methyldopa (3-OMD)
  • Prevents conversion of Dopamine to 3-methoxtyramine (3-MT)
  • Provides greater % of l-dopa to cross BBB & Dopamine in brain

COMT inhibitor

(Entacapone & Tolcapone)

10

Which drug?

  • Attenuate motor fluctuations in carbidopa/l-dopa treated pts
  • Modest symptomatic benefit as monotherapy
  • Benefit may be from neuroprotective effect
  • NO benefit as a monotherapy as it may not get more levodopa into the brain

COMT inhibitors (catechol-O-methyl-transferase)

(Entacapone & Tolcapone)

11

Adverse effects of which drug?

  • Relates to increased levels of L-dopa
  • Dyskinesias
  • Confusion
  • Liver toxicity *
  • Orthostatic hypotension

COMT inhibitors

(Entacapone & Tolcapone)

Tolcapone specifically toxic to liver**

12

Which drug has these drug interactions?

  • L-dopa reduces dose
  • Antidiarrheals reduce dose

COMT inhibitors 

(Entacapone & Tolcapone)

13

What should you monitor in a patient taking COMT inhibitors (Entacapone & Tolcapone)? 

LFTs

14

Which drug?

  • MOA: stimulates dopamine activity on the nerves in the subtantia nigra and striatum
  • Pramipexole is the "prototype"
  • Causes doing things in excess like spending money / gambling

Dopamine Agonists

(Amantadine)

15

Adverse Effects of which drug?

  • **Postural hypotension**
  • Pulmonary fibrosis
  • Confusion
  • Hallucinations
  • Sedation
  • Vivid dreaming
  • **Impulsive Behaviors**

(Underlined = Psychosis)

Dopamine Agonists

(Amantadine)

16

When should you consider giving pt Amantadine?

If pt is older and doesn't want to go on l-dopa

17

Which drug?

  • Enhances dopamine release
  • Blocks glutamatergic N-methyl-D-aspartate (NMDA) receptors

Amantadine (Dopamine Agonist)

18

What 3 things does Amantadine (Dopamine Agonist) improve in PD pts?

  • Tremors
  • Rigidity
  • Bradykinesia

19

Adverse effects of which drug?

  • Dizziness
  • Dry mouth
  • Hallucinations
  • Livedo reticularis

Amantadine (dopamine agonist)

20

  • Which drug has adverse reactions similar to anticholinergics?
  • What are the 5 effects?

Amantadine (dopamine agonist)

  • Mad as a hatter
  • Blind as a bat
  • Dry as a bone
  • Red as a beet
  • Hot as a hair

21

  • What drug provides "symptomatic benefit,"
  • but less than that of dopamine agonists or carbidopa/l-dopa
  • Useful add-on agent to attenuate dyskinesias

Amantadine

22

  • An aporphine alkaloid originally derived from morphine, but lacks narcotic properties
  • Bc of poor oral bioavailability due to extensive hepatic 1st pass metabolism
  • Is administered subcutaneously
  • Indicated for pts w/ advanced PD who are experiencing intermittent off episodes despite optimized therapy

Apomorphine

23

  • Upon subcutaneous administration, apomorphine produces an "on" response within ___ minutes. 
  • Sites of injection (abd, UE, upper thigh) should be rotated to avoid development of ____ ____. 
  • Apomorphine elimination half life is approximately ___ minutes and duration of benefit can be up to ____ minutes. 

  • 20 mins
  • Subcutaneous nodules
  • 40 minutes
  • 100 minutes

24

What should patients be "premedicated" w/ before receiving Apomorphine?

Trimethobenzamide

(antiemetic)

25

If drug overdose, give what med? Which causes nausea and vomiting. 

Apomorphine

26

Tx of what effect?

  • Increase frequency of carbidopa/L-dopa doses
  • Add either COMT inhibitor or MAO-B inhibitor or dopamine agonist 

End-of-dose "wearing off" 

(motor fluctuation)

27

Tx of what effect?

  • Give carbidopa / L-dopa on empty stomach 
  • Use carbidopa/L-dopa ODT
  • Avoid carbidopa/L-dopa CR (long acting)
  • Use apomorphine subcutaneous

"Delayed on"

"no on" response

28

Tx of what effect?

  • Increase carbidopa/L-dopa dose
  • Add a dopamine agonist or MAO-B inhibitor
  • Utilize physical therapy along w/ assistive walking devices or sensory cues
  • (rhythmic commands, stepping over objects)

Start hesistation (freezing)

29

Tx of what effect?

  • Provide smaller doses of carbidopa/L-dopa
  • Add amantadine

Peak-dose dyskinesia

30

A form of carbidopa / levodopa delivered in gel form, called enteral suspension

Duopa

31

  • Used to treat the motor sxs of PD
  • Surgical placement of enteral tube in stomach wall to place a tube in your intestine
  • Pump then delivers ____ directly to the intestine

Duopa

32

Duopa uses the same active ingredients as orally administered ____ _____, but is designed to improve absorption and reduce off times by delivering the drug directly to the small intestine. 

Carbidopa / Levodopa

33

What drug do you give on empty stomach?

L-lopa/Carbidopa

34

Surgery should be considered an adjunct to pharmacotherapy when pts are experiencing _____ or ______ or ______ despite an optimized medical regimen. 

  • frequent motor fluctuations 
  • disabling dyskinesia
  • tremor

35

____ DBS (Deep Brain Stimulation) is very effective for suppressing tremor specifically ___ tremor, but it does not significantly improve the other parkinsonian features (bradykinesia, rigidity, motor functions, or dyskinesias)

  • Thalamic
  • arm

36

Both ____ and ____ are associated w/ improvements in tremor, rigidity, bradykinesia, motor fluctuations, dyskinesia, and activities of daily living, however, _____ allows for greater reduction in medications. 

  • STN and GPi DBS
  • STN DBS

37

As with pharmacotherapy, DBS uncommonly improves ____ or _____. 

Gait or postural instability

38

  • Excess dopamine results in ______ sxs
  • When we tx _____, it looks like Parkinsons

  • schizophrenia