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Parkinson's Disease Flashcards

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1
Q

Is Parkinson’s more common in males or females?

A

males

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2
Q

What are the primary patho features of Parkinson’s?

A

loss of dopaminergic cells in substantial nigra & basal ganglia

formation of Lewy bodies

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3
Q

What are the non-pharm options for Parkinson’s?

A

surgery

physical therapy & exercise

nutrition (fluids & fiber to prevent constipation)

occupational therapy & fall prevention

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4
Q

What 4 mechanisms are used to treat Parkinson’s?

A
  1. decrease cholinergic activity
  2. increase endogenous dopamine
  3. activate dopamine receptors w/ synthetic agonists
  4. block adenosine A2A receptor
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5
Q

Which anticholinergics are used in Parkinson’s

A
  1. benzotropine (Cogentin)
  2. trihexyphenidyl (Artane)
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6
Q

What is the issue with using levodopa alone?

A

very little can cross BBB without a decarboxylase inhibitor

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7
Q

What is the purpose of carbidopa in Parkinson’s

A

decarboxylase inhibitor, combo w/ levodopa -> to get levodopa to the CNS and decreases peripheral ADR

USELESS AS MONOTHERAPY

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8
Q

What are the CI of levodopa?

A

breastfeeding

closed angle glaucoma

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9
Q

What are the CI of carbidopa?

A

pregnancy

lactation

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10
Q

What is the minimum carbidopa dose needed to decrease GI ADR from levodopa?

A

70-100 mg/day

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11
Q

What are the carb/levo brands/formulations?

A
  1. Sinemet IR & CR, PO
  2. Duopa, intestinal gel via wearable pump w/ J-tube
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12
Q

What is Inbrija?

A

levodopa powdered inhalation

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13
Q

What is the indication for Duopa?

A

advanced PD

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14
Q

If a patient is on oral carb/levo before switching to Duopa what is required of the oral regimen?

A

must be put on IR to switch to the pump

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15
Q

How should you adjust the dose when switching from IR to CR carb/levo?

A

decrease the frequency by 50% and consider a dose increase by 25%/day

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16
Q

What are the benefits of using CR carb/levo over IR?

A

decreased time “off”

dec dosing frequency

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17
Q

What are the typical carb/levo ratios?

A

1:4 (IR also has 1:10)

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18
Q

What is the indication for Inbrija?

A

supportive PRN therapy for intermittent “off” periods

NOT a replacement for PO carb/levo

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19
Q

What is a CI for Inbrija?

A

use of a MAOI in last 2 weeks

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20
Q

What Parkinson’s agent can cause black saliva/nasal secretions?

A

Inbrija (levodopa powder inhalation)

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21
Q

What COMT inhibitors are used in Parkinson’s?

A
  1. entacapone (Comtan)
  2. tolcapone (Tasmar)
  3. opicapone (Ongentys)
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22
Q

Which COMT inhibitor has the shortest half life?

A

entacapone (Comtan)

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23
Q

What is the indication for COMT inhibitors in PD?

A

adjunct therapy to extend effect of levodopa (prevents breakdown)

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24
Q

How is entacapone dosed?

A

200mg with EACH DOSE of carb/levo

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25
What is Stalevo?
carb/levo, entacapone 1:4, 200 mg
26
What type of meal decreases levodopa absorption?
high protein
27
How is tolcapone (Tasmar) dosed?
100 mg TID
28
How is opicapone dosed?
50 mg QHS (no food 1 hour before/after)
29
What Parkinson's agent has an ADR of brown/orange urine?
entacapone (Comtan)
30
Which COMT inhibitor has a risk of induced hepatocellular injury?
tolcapone (Tasmar)
31
What COMT inhibitor is contraindicated in hepatic disease?
tolcapone (Tasmar)
32
What are the CI for opicapone (Ongentys)
MAOI use catecholamine secreting neoplasms (pheochromocytoma, paraganglioma)
33
What type of MAOI inhibitors can be used for Parkinson's?
MAOI ****B***** inhibitors
34
What MAOI B inhibitors are used in Parkinson's?
1. selegiline (Eldepryl, Zelapar) 2. rasagiline (Azilect) 3. safinamide (Xadago)
35
Which Parkinson's agent is potentially disease modifying?
rasagiline (Azilect)
36
What makes safinamide (Xadago) stand out among PD MAO-B inhibitors?
is also a Na & K channel blocker
37
What Parkinson's agents can be used as mono therapy in healthy patients and potentially delay need for levodopa?
selegiline (Eldepryl, Zelapar) & rasagiline (Azilect)
38
What is the purpose of MAO B inhibitors as adjunct to levodopa?
decrease the dose of levodopa needed
39
What are common ADR of selegiline (Eldepryl, Zelapar)? What causes these ADR?
insomnia, jitteriness, hypertensive crisis selegiline has 3 active amphetamine metabolites
40
What is the indication for MAO-B inhibitor safinamide (Xadago)?
adjunct therapy to levodopa for wearing "off" symptoms
41
What MAO-B inhibitor is contraindicated in Child-Pugh Class C?
safinamide (Xadago)
42
What is the use of amantadine (Symmetrel IR, Gocovri ER) in Parkinson's?
adjunct for patients on high doses of levodopa to REDUCE L-DOPA INDUCED DYSKINESIA
43
What is a unique ADR of amantadine?
livedo reticularis - idiosyncratic skin mottling & lower extremity edema
44
What is a common ADR of amantadine?
anticholinergic effects
45
What is the place is therapy for dopamine agonists in Parkinson's?
mono therapy in young, healthy patients adjunct w/ levodopa for pt with diminished response to levodopa
46
ADR of dopamine agonists compared to levodopa dec risk of ________ inc risk of ________
dec risk of motor ADR inc risk of non-motor ADR (psych symptoms, N/V, sedation, hypotension)
47
What dopamine agonists used for Parkinson's?
1. pramipexole (Mirapex) 2. ropinirole (Requip) 3. rotigotine (Neupro) 4. apomorphine (Apokyn)
48
Which dopamine agonist for Parkinson's is metabolized by CYP1A2?
ropinirole (Requip)
49
Which dopamine agonist for Parkinson's is a transdermal patch?
rotigotine (Neupro)
50
What is the minimum effective dose for Parkinson's of a rotigotine (Neupro) patch?
4 mg/24 h
51
Which dopamine agonist for Parkinson's is given subQ?
apomorphine (Apokyn)
52
What is the indication for apomorphine (Apokyn)?
advanced PD as a PRN adjunct for unpredictable "off" episodes
53
What is needed to start using apomorphine (Apokyn) PRN?
test dose with blood pressure monitoring
54
What agent is given alongside apomorphine (Apokyn) to manage an ADR? What are some pearls of the addition of said agent?
antiemetic - no 5HT3 antagonists -> contraindicated! - typically use antihistamine (trimethobenzamide - Tigan)
55
What is the adenosine A2A receptor antagonist used for Parkinson's?
istradefylline (Nourianz)
56
What is the indication for istradefylline (Nourianz)?
combo therapy w/ carb/levo in patients w/ "off" episodes (decreases "off" time)
57
When are dose adjustments needed for istradefylline (Nourianz)? (3 scenarios & the adjustment)
smokers (20 cigs/day) -> need max dose (40mg QAM) moderate hepatic impairment (Class B) -> stay on starting dose (20mg QAM) concomitant strong CYP3A4 inhib -> MAX dose of 20 mg QAM
58
PD Treatment Complications: What adjustments can be made to help with wearing off or on-off response?
increase levodopa frequency or switch to CR ADD adjunct dopamine agonist, MAO-B inhib, COMT inhib, amantadine, istradefylline (Nourianz)
59
PD Treatment Complications: What adjustments can be made to help with off, NO on?
increase levodopa dose, frequency, water switch to ODT if advanced PD -> subQ apomorphine or Duopa
60
PD Treatment Complications: What adjustments can be made to help with delayed onset?
take on empty stomach, water & avoid protein if on CR -> switch to IR or ADD IR
61
PD Treatment Complications: What adjustments can be made to help with peak effect dyskinesia?
decrease levodopa dose/increase frequency ADD amantadine switch to CR or dopamine agonist
62
PD Treatment Complications: What adjustments can be made to help with dystonia?
use CR levodopa QHS to help w/ AM symptoms ADD dopamine agonist, baclofen, botox
63
PD Treatment Complications: What adjustments can be made to help with freezing?
increase levodopa dose ADD dopamine agonist gait modification & physical therapy
64
PD Treatment Complications: What agents can be used to treat depression?
pramipexole venlafaxine TCAs (notriptyline, desipramine) SSRIs
65
PD Treatment Complications: What agents can be used to treat dementia/cognitive impairment?
AChE inhibitors: rivastigamine donepezil galantamine
66
PD Treatment Complications: What agents can be used to treat insomnia?
eszopiclone melatonin
67
PD Treatment Complications: What agents can be used to treat daytime somnolence?
modafinil
68
PD Treatment Complications: What agents can be used to treat orthostatic hypotension?
droxidopa (SHORT TERM ONLY) fludrocortisone midodrine
69
PD Treatment Complications: What agents can be used to treat sexual dysfunction?
sildenafil
70
PD Treatment Complications: What agents can be used to treat constipation?
probiotics & fiber PEG lubiprostone
71
PD Treatment Complications: What agents can be used to treat drooling?
botox glycopyrrolate
72
Steps to address psychosis in PD:
1. rule out other causes -> hypoxemia, infection, electrolyte disturbances 2. simplify regimen (D/C higher risk agents first) 3. consider atypical antipsychotic
73
In what order should a Parkinson's regimen be simplified when a pt has psychosis? (list out drugs from 1st to last removed)
1. anticholinergics 2. taper & D/C amantadine 3. selegiline 4. taper & D/C dopamine agonists 5. consider decreasing levodopa & D/C COMT inhib

Therapeutics (18 decks)

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