Parkinson Disease

Question 1

Pathophysiology of PD

Answer 1

Degenerative disease → neurons die → ↓ dopamine that leads to uncoordinated muscle function and movement

Question 2

Sx of PD

Answer 2

Tremors when resting
Rigidity
Akinesia/bradykinesia
Postural instability

Question 3

How to measure severity of PD sx

Answer 3

Abnormal involuntary movement scale

Question 4

Drugs that block dopamine

Answer 4

Antipsychotics
Metoclopramide

Question 5

Preferred drugs for psychosis in patients with PD

Answer 5

Quetiapine (low risk of movement disorders)
Clozapine (low risk of movement disorders but higher risk for seizures)

Question 6

Tx for PD

Answer 6

Replace dopamine:
- Dopamine agonsit
- ↑ dopamine (levodopa +/- COMT)
- Symptomatic relief

Question 7

MOA of Sinemet

Answer 7

Levodopa: Precursor of dopamine
Carbidopa: inhibits the dopa decarboxylase enzymes → prevents the peripheral metabolism of levodopa

Question 8

How to dose Sinemet formulations

Answer 8

Titrate cautiously to avoid NMS

IR starting dose: 25/100 mg PO TID
ER tab can be cut in half
Rytary: take whole or sprinkle on applesauce

Don’t DC abruptly

Question 9

CI of Sinemet

Answer 9

Avoid non selective MAO inhibitors

Question 10

ADR of Sinemet

Answer 10

N, DZ, orthostasis, dyskinesia (long-term), hallucinations, psychosis

Brown, black, or dark urine
Unusual sexual urges, priapism

Coombs test for hemolytic risk

Question 11

Dose of carbidopa to effectively inhibit dopa decarboxylase

Answer 11

70-100 mg/day

Question 12

MOA of COMT inhibitor

Answer 12

↑ the duration of action of levodopa → inhibit COMT to present the conversion of levodopa

Must be only used with levodopa

Question 13

Types of COMT inhibitors

Answer 13

Entacapone
Opicapone
Tolcapone

Question 14

Entacapone

Answer 14

Comtan

Question 15

Starting dose of Entacapone

Answer 15

200 mg PO with each dose of Sinemet

Max: 1600 mg/day

Question 16

ADR of Entacapone

Answer 16

Same as levodopa due to extended duration

Question 17

Food to limit when on SInemet

Answer 17

Iron and protein-rich can ↓ absorption

Question 18

Types of dopamine agonist

Answer 18

Pramipexole
Ropinirole
Rotigotine
Apomorphine

Question 19

Pramiprexole

Answer 19

Mirapex

Question 20

Ropinerole

Answer 20

Requip

Question 21

Rotigotine

Answer 21

Neupro

Question 22

ADR of dopamine agonist

Answer 22

Solmnolense, daytime sleep attacks, orthostasis, hallucinations, dyskinesias

Rotigotine: application site skin reactions

Question 23

Counseling of Neupro

Answer 23

Apply QD at the same time each day to the stomach, thigh, hip, side of the body, shoulder, or upper arm

Don’t use the same site for at least 14 days

Remove the patch before MRI

Avoid in sulfite allergies

Question 24

Indication of apomorphine

Answer 24

Used as a “rescue” movement drug for off periods

Question 25

Adminsitration of apomorphine

Answer 25

Must be started with a test dose in medical office

Question 26

CI of apomorphine

Answer 26

Avoid with 5-HT3 antagonist → severe hypotension and loss of consiousness

Question 27

ADR of apomorphine

Answer 27

Severe nausea, vomiting, hypotension

Question 28

How to mitigate nausea with apomorphine

Answer 28

Trimethobenzamide (Titan)q

Question 29

MOA and indication of amantadine

Answer 29

Blocks the reuptake of dopamine into presynaptic neurons to ↑ dopamine in presynaptic fibers Indication: dyskinesia with peak doses of Sinemet

Question 30

MOA and indication for Selective MOA-B inhibitors

Answer 30

Block the breakdown of dopamine to ↑ dopaminergic activity Use a adjuct to Sinement, but Rasagiline is indicated as monotherapy

Question 31

Selecte MAO-B inhibitors

Answer 31

Selegiline Rasagiline Safinamide

Question 32

Seleginine

Answer 32

Zelpar (ODT) Ensam (Patch for depression)

Question 33

Rasagiline

Answer 33

Azilect

Question 34

Safinamide

Answer 34

Xadago

Question 35

Counseling on Seleginine

Answer 35

Drug is activating → avoid taking at bedtime

Question 36

CI and ADR of Selective MOA-I

Answer 36

Avoid combination of other MOAs, opioids, SNRIs, TCA Xadago: severe hepatic impairment Serotonine syndrome, HTN

Question 37

Indication for anticholinergics

Answer 37

Tremors

Question 38

Anticholinergics used for tremors

Answer 38

Benzotropine Trihexyphenidyl

Question 39

ADR of anticholinergics

Answer 39

Dry mouth, constipation, urinary retention, blurred vision, mydriasis, somnolence, confusion

Question 40

Indication for adenosine receptor antagonists

Answer 40

Used in combo with Sinemet to reduce off episodes

Question 41

Indication for a/b agonist

Answer 41

Neurogenic orthostatic hypotensio

Question 42

Type of adenosine receptor antagonist

Answer 42

Istradefylline

Question 43

Drug used to mitigate neurogenic orthostatic hypotension

Answer 43

Droxidopa

Question 44

ADR of droxidopa

Answer 44

Syncope, falls, HA

Question 45

Foods to avoid with MOAI

Answer 45

Tyramine: fermented, aged, cured

Question 46

What is an off episode

Answer 46

When the sx of a disease worsen before the next dose of medication is due