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PR3153 Psychiatry > Parkinson's Disease > Flashcards

Parkinson's Disease Flashcards

1
Q

Cardinal Motor Symptoms of PD

A

TRAP: 2 out of 3 (TRA) suggests PD
1. Tremors at Rest
2. Rigidity (Cogwheel)
3. Akinesia (Subjective weakness, facial)
4. Postural Instability

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2
Q

5 Non-motor symptoms associated with PD

A
  1. Cognitive (Dementia)
  2. Psychiatric (Depression, Psychosis)
  3. Sleep disorder
  4. Autonomic disorder (Constipation, GI motility, Orthostatic hypotension, Sialorrhea)
  5. Fatigue
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3
Q

Activities of Daily Living: DEATH

A

Dressing
Eating
Ambulating
Toileting
Hygiene

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4
Q

Pathophysiology of PD

A

Dopaminergic Neuron Degeneration in the Substantia Nigra which normally inhibit a number of motor systems
- Hypoactivation of D1 receptors weaken striatal inhibition
- Hypokinesia

Accumulation of toxic Lewy body protein

Nigrostriatal pathway dysfunction

Reduced basal ganglia “action selection” and poor motor control

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5
Q

How to treat drug-induced Parkinsonism?

A

May not always be reversible

Prevention is key

Anticholinergics and Amantadine can be used

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6
Q

Differentiate drug-induced PD and idiopathic PD

A

DIP VS iPD
Age Onset: Elderly vs ≥ 60 years old
Symptom Onset: Symmetrical vs Asymmetrical
Time Onset: Acute vs Chronic Progressive
Levodopa Test: Poor vs Marked

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7
Q

List 5 medications associated with drug-induced Parkinsonism

A
  1. Antipsychotics
  2. Anti-seizure Medications
  3. Antiemetics (Metoclopramide)
  4. Calcium Channel Blockers (NDHP)
  5. Lithium, Tetrabenazine, Reserpine, Methyldopa
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8
Q

Drug Classes and MOA for PD management

A

Central Dopamine Pathway:
1. Levodopa (Synthetic precursor)
2. Dopamine agonists (Pramipexole, Rotigotine)
3. MAO-B Inhibitors (Selegiline, Rasagiline)
4. COMT Inhibitors (Entacapone)

Other Pathways to correct Imbalance:
1. Anticholinergics (Trihexyphenidyl)
2. NMDA Receptor Antagonist (Amantadine)

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9
Q

Levodopa Brands, Combinations, Formulations and Rationale

A

Combination with Carbidopa / Benserazide
- DCI 75-100 mg required
- Peripheral Conversion by DOPA decarboxylase in the gut => DCI increases bioavailability

Brands (L-dopa : DCI)
- Sinemet (1:4, 1:10)
- Madopar (1:4)

Formulation
- Immediate or Controlled / Modified Release
- Considerations for wearing off effect

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10
Q

Levodopa ADME, DDI and considerations for counseling

A

Absorption is affected by protein and fat intake because levodopa is absorbed by an active saturable carrier system for large neutral amino acids. Take on empty stomach.

Drug Interactions:
- Pyridoxine high dose (Not a problem if DCI combination as pyridoxine is a cofactor for DOPA decarboxylase)
- Iron: Space out administration
- Protein: Space out administration
- Dopamine antagonists (Antipsychotics, antiemetics): Antiemetic of choice is domperidone

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11
Q

Levodopa ADRs and when does dyskinesia commonly onset?

A
  • GI effects: N/V
  • DA effects: Orthostatic Hypotension
  • CNS effect: Drowsy, sudden sleep onset, hallucination, psychosis
  • Long term: Dyskinesia (After 3 to 5 years of initiation)
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12
Q

What is dyskinesia? How do you manage it?

A

Involuntary uncontrollable twitching, jerking, and dystonia

Add amantadine or replace specific doses with CR Levodopa

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13
Q

List 2 motor complications of levodopa and how to manage them

A
  1. On-off Phenomena: Unpredictable
  2. Wearing Off Effect as disease progresses:
    - Modify timing of medication intake
    - Modify formulation use
    (Increased to 4-6h release period)
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14
Q

Formulation conversion for levodopa

A

IR to CR: Increase the dose by 25-50%

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15
Q

Types of dopamine agonists and the disadvantage of one over the other

A

Ergot: Lower bioavailability (First pass)
- Bromocriptine
- Cabergoline
- Pergolide

Non-ergot
- Rotigotine (Transdermal)
- Pramipexole
- Apomorphine (Subcut)
- Ropinirole

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16
Q

What is better about dopamine agonists compared to levodopa?

A

Longer half-life and duration of action

17
Q

Comment on the elimination of dopamine agonists

A

Ropinirole: Liver metabolism to inactive metabolites

Pramipexole: Renal excretion unchanged

18
Q

Dopamine agonist ADRs

A

Central Dopaminergic:
- Hallucination
- Somnolence, Day-time sleepiness
- Compulsive behaviors

Peripheral Dopaminergic:
- Nausea, vomiting
- Orthostatic hypotension
- Leg edema

Non-dopaminergic:
- Fibrosis
- Valvular heart disease

19
Q

Compare the ADRs, efficacy and place in therapy of levodopa and dopamine agonists.

A

Levodopa has more motor complications but dopamine agonists have more hallucinations, sleep disturbances, leg edema, orthostatic hypotension

Efficacy is similar

Dopamine agonists for younger patients (Young onset PD monotherapy) or adjunct to severe PD

20
Q

Why do MAO-B Inhibitors have a 14-day washout period?

A

Selegiline and Rasagiline are IRREVERSIBLE inhibitors.

MAO regeneration takes 14-28 days

21
Q

Why should selegiline be dosed no later than 4pm?

A

Hepatic metabolism to amphetamine increases wakefulness (stimulating) and have no effect on MAO-B.

22
Q

Dosing of MAO-B Inhibitors

A
  1. Selegiline 5 mg OM to BD
  2. Rasagiline 0.5 to 2 mg QD
23
Q

MAO-B Inhibitor DDIs

A
  1. Antidepressants (SSRIs, SNRIs, TCAs)
  2. Linezolid
  3. Opioids (Pethidine, Tramadol)
  4. Sympathomimetics
  5. Dextromethorphan
24
Q

MAO-B Inhibitor Food interactions

A
  1. Cheese (Tyramine rich food)
  2. Red Meat
  3. Fermented Food
25
Q

When do we use MAO-B Inhibitors?

A

Monotherapy in early stages
Adjunct in later stages
Young Onset PD (Common)

26
Q

When are COMT Inhibitors considered effective?

A

When used concurrently with levodopa. When DCI is used, COMT is the major metabolizer.

27
Q

What are COMT inhibitor DDIs?

A
  • Iron, calcium
  • Concurrent non-selective MAOi
  • Catecholamine drugs
  • Warfarin
28
Q

Entacapone ADRs (4D)

A

Diarrhea
Urine discoloration (Orange)
Dyskinesia (Initiation: Reduce Levodopa dose)
Dopaminergic effects potentiated (Orthostatic hypotension, N/V)

29
Q

In whom should COMT inhibitors be used with caution?

A

Hepatic impairment

But not needed to monitor LFTs

30
Q

When is amantadine dose reduction needed?

A

Renal impairment (Because renal excretion)

31
Q

When should amantadine be dosed?

A

BD dosing with the second dose in the afternoon because it can be stimulating

32
Q

What ADRs and DDIs to take note off for amantadine?

A

DDI: Memantine

ADR: Nausea, lightheadedness, insomnia, confusion, hallucination, livedo reticularis (skin discoloration)

33
Q

Amantadine Place in Therapy

A

Adjunct

Manage Levodopa-induced dyskinesias

PR3153 Psychiatry (10 decks)

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