Parkinson's Disease Flashcards
(25 cards)
Parkinson’s: SX
Less dopamine = less instructions to brain = movement problems (TRAP)
T = tremor
R = rigidity
A = akinesia/bradykinesia (lack of or slow start in movement)
P = postural instability (imbalance, falls)
AIMS = abnormal involuntary movement scale (measures involuntary movements from meds like tardive dyskinesias)
Dopamine Blocking Drugs That Can Worsen Parkinson’s
-Prochlorperazine
-Haloperidol, droperidol
-Risperidone, paliperidone (lowest risk with quetiapine)
-Metoclopramide
MR PQ got a PHD
Parkinson’s: TX Principles
Replace dopamine
1. give a drug that mimics dopamine (dopamine agonist)
2. give a drug that increases dopamine (levodopa +/- COMTi)
3. give sx tx (AC for resting tremor)
Levodopa = most effective
*carbidopa given with levodopa to prevent breakdown of levodopa outside of the CNS (would destroy most of drug before reaching BBB)
*better tolerated than dopamine agonist for INITIAL tx in adults
Tremor-dominant Disease in Younger Patients
= Benztropine (centrally acting AC)
*due to AE = on Beers = difficult to use in older patients
Carbidopa/Levodopa (Sinemet)
IR: 25/100 mg TID
ER: 50/200 mg BID
-ER TAB CAN BE CUT IN HALF
CI:
-Phenelzine, isocarboxazid within 14d
-Narrow angle glaucoma
AE:
-Nausea
-Dizziness
-Orthostasis
-Dyskinesias
-Hallucinations, confusion
-Psychosis
-Dry mouth (xerostomia)
-Dystonias
*Can cause brown/black urine/saliva/sweat
*Hemolysis risk (Coombs)
*Unusual sexual urges
*Priapism
LEV eats CARBs - BC PIG SHOP
How much carbidopa required to inhibit dopa decarboxylase?
70-100 mg/day of carbidopa
Long-term use of Carbidopa/Levodopa
Long-term use can lead to fluctuations in response and dyskinesias
Do not DC abruptly (must be tapered)
Duopa cassettes
Store in freezer, thaw in fridge, good for 12 weeks upon refrigeration
Rytary-specific AE
Rytary = ER capsule of carb/levo
SI and attempts
COMT inhibitors (CAPONES): AE/Notes
Entacapone, Opicapone, Tolcapone
*ONLY used with levodopa (no mono)
*MOA: increase duration of levodopa
Entacapone: 200 mg with EACH dose of carb/levo (max 1600 mg/day)
AE: similar to levodopa
Notes:
-Dec in levodopa dose of 10-30% is usually necessary when adding on a COMTi
-Dyskinesias can occur earlier with COMTi
-Tolcapone: rarely used due to hepatotoxicity risk
CAP- Tee keep it on the DL DL
Dopamine Agonists: Pramipexole, Ropinirole, Rotigotine
Pramipexole (Mirapex) and Ropinirole (Requip) and Rotigotine (Neupro)
Warnings:
-Somnolence (daytime sleep attacks)
-Orthostasis
-Hallucinations
-Dyskinesias (involuntary movements)
-Impulse control disorders
Do not DC abruptly
PRR DID SHOA
Pramipexole-specific AE
-Postural deformity (bent spine, dropped head)
-Rhabdo
PRAM = PRP
Rotigotine (Neupro): Patch
-Apply once daily at same time each day
(stomach, thigh, hip, side of body, shoulder, upper arm)
-Do not use at the same site for at least 14 days
-Remove the patch before MRI
-Avoid if allergy/sens to sulfites
= ROT and SMD for 14 days
Apomorphine (Apokyn): CI/AE
Used as rescue movement drug for “OFF” periods, treats severe “freezing” episodes
Must do a test dose in a medical office
= FOT
CI
-Do not use with 5HT3s (ondansetron) due to hypotension and loss of consciousness
AE
-Severe NV
-Hypotension
-Yawning, somnolence
-QTP
-Dyskinesias
For emesis ppx: give trimethobenzamide (Tigan) 300 mg PO TID or similar one, started 3d prior to the initial dose
Carbidopa/Levodopa: DDI
CI with MAOi (2 week separation
Iron and protein rich foods can decrease absorption
Do not use with dopamine blockers (Phenothiazines, metoclopramide)
PPIMM
Amantadine: AE/Notes
Blocks dopamine reuptake
Warnings:
-Somnolence (falling asleep without warning during daily activities)
-Compulsive behaviors
-Psychosis (hallucinations, delusions)
AE:
-Dizziness
-Orthostatic hypotension
-Abnormal dreams
-Livedo reticular (red skin mottling)
AVOID LIVE VACCINES WITH THIS
P SCOLLD a man for his DREAMS
MAOBi (Sele, Rasa, Safi): CI/Notes
Selegiline, Rasagiline, Safinamide
-block breakdown of dopamine
CI:
-Use with other MAOI (linezolid), opioids, SNRI, TCAs
W:
-Serotonin syndrome
-HTN
-Impulse control disorders
May need to reduce levodopa dose when beginning treatment with a selective MAOBi
SRS HIS LOST
Xadago-specific AE
Severe hepatic impairment (CI)
Caution in ophthalmic disorders
= LEX = eye and liver
Rasagiline-specific AE
Can be used as mono therapy (only this one)
AE: headache, joint pain, indigestion
RASA and HAMJI
Benztropine (Cogentin): AE
High incidence of peripheral and central anticholinergic effects:
-dry mouth
-constipation
-urinary retention
-blurred vision
-mydriasis **(PUPIL DIALATION) **
-somnolence
-confusion
Avoid in older adults
*same for trihexyphenidyl
Used for neurogenic orthostatic hypotension
Droxidopa (Northera)
BBW: supine HTN
AE: syncope, falls, HA
Used in combination with carbidopa/levodopa to reduce “off” episodes
Istradefyline (Nourianz)
-adenosine receptor antagonist
Warnings:
-Hallucinations, dyskinesias, impulse control disorders
MAOBI: DDIs
-Tyramine foods (aged cheese, air dried or cured meats - sausages, salamis, sauerkraut, fava or bean pods, beers, marmite, soy sauce, soybean condiments)
-Dopamine
-Phenylalanine
-Tryptophan
-Caffeina
-Tyrosine
Rasagiline: DDI
CYP1A2 substrate
-Limit dose to 0.5 mg daily with ciprofoxacin or other CYP1A2 inhibitors
