Parkinson's Disease Flashcards
(127 cards)
1
Q
*The 3 cardinal signs of PD are: __, __, __.
A
Akinesia/Bradykinesia
Rigidity
Tremors
2
Q
*Subjective sense of weakness, loss of dexterity, difficulty using kitchen tools, loss of facial expression, reduced blinking, difficulty getting out of bed/chair, difficulty turning while walking.
These are a sign of __.
A
Akinesia/Bradykinesia (Cardinal sign of PD)
3
Q
*A patient describes “ratchet”-like stiffness (cogwheel rigidity); also leadpipe rigidity.
These are a sign of __.
A
Rigidity (Cardinal sign of PD)
4
Q
*Resting tremors that disappears with movement), but increases with stress. A pill rolling movement around 4-8hz may be observed.
These are a sign of __.
A
Tremors (Cardinal sign of PD)
5
Q
A patient presenting with idiopathic PD will usually have: \_\_ features Positive response to \_\_/\_\_ \_\_ progression of PD No presence of \_\_ or \_\_
A
- Asymmetric
- levodopa/apomorphine
- Slow
- postural instability i.e. falls or autonomic dysfunction
6
Q
*PD pts are unable to perform these Activities for daily living (ADLs). They include:
A
–Mobility (walking, using stairs) –Feeding self –Grooming, personal hygiene –Toileting –Showering/bathing –Continence (bowel and bladder)
7
Q
*PD pts experience interference to their ADLs in the form of:
A
•Choking
•Pneumonia
•Falls
(CPF)
8
Q
Rapid PD disease progression is defined as __.
A
H and Y stage 3 after 3 years
9
Q
As the H and Y scale progresses from 1 to 5, there is increasing disability and dependence. H and Y stage 3 refers to __.
A
Impaired postural reflexes
Physically independent
10
Q
The ‘ON’ state for PD patients refers to __.
A
when pt is responding to levodopa
11
Q
The ‘OFF’ state for PD patients refers to __.
A
when pt is not responding to levodopa
12
Q
The H and Y scale assess __. Patients on treatment should be assessed in their __ and __.
A
- mobility
2. ON and OFF states
13
Q
Non-motor symptoms of PD may lead to: \_\_ impairment \_\_ symptoms \_\_ disorders \_\_ dysfunction Fatigue Non-motor symptoms are monitored by the UPDRS scale.
A
- Cognitive
- Psychiatric
- Sleep
- Autonomic
14
Q
Young-onset PD pts generally have __ disease progression, __ decline and __ motor complications (with treatment).
A
slower
less cognitive
earlier
15
Q
__ is a more common initial presentation for young-onset PD vs __ and __ in late-onset
A
Dystonia
falls and freezing
16
Q
The use of __ treatment is preferred to levodopa in young-onset PD in order to __
A
Dopamine agonist
delay onset of levodopa induced motor complications
17
Q
*The goal of PD management is to __, __ and __. It is not curative and no PD treatment has been shown to be neuroprotective.
A
Manage symptoms, maintain function/autonomy
18
Q
*The focus of pharmacological treatment in PD is to increase central dopamine, dopaminergic transmission. There are 4 classes which include:
A
- Levodopa + DCI
- Dopamine agonists
- COMT inhibitors
- MAO-B inhibitors
19
Q
Non-pharmacological options for PD patients include:
- __ (Stretching, transfers, posture, walking)
- __ (Mobility aids, home and workplace safety)
- Speech and __
- Surgery
A
- Physiotherapy
- Occupational therapy
- Swallowing
20
Q
Correcting imbalances in pathways are a viable pharmacological treatment option, but are not very good in __.
A
relieving cardinal symptoms of PD
21
Q
*Levodopa is the most effective drug for treatment of symptoms, especially bradykinesia and rigidity. It is less effective for __, __ and __.
A
speech, postural reflex and gait disturbances
22
Q
*Peripheral conversion of levodopa can cause __ and __. Therefore, it makes sense that levodopa has a DDI with alpha blockers as it __, increasing fall risk.
A
N/V and hypotension
increases postural hypotension
23
Q
*Levodopa has drug-food interactions, which is __ and __. As a result, the 2 should be spaced 2-4h apart.
A
lowered absorption with high fat/protein meals and iron
24
Q
__ of DCI is required to saturate Dopa decarboxylase daily. It does not cross the BBB.
A
75-100mg
25
What is the formulation and strength ratio for Sinemet?
25mg Carbidopa : 100mg levodopa (1:4)
| 25mg Carbidopa : 250mg levodopa (1:10) - SR/CR
26
What is the formulation and strength ratio for Madopar?
25mg Benserazide : 100mg levodopa (1:4)
| 25mg Benserazide : 250mg levodopa (1:10)
27
*Levodopa induced dyskinesias have a usual onset of __.
within 3-5years of initiating treatment
28
* Levodopa has CNS side effects which include:
- __, sudden sleep onset
- hallucinations and __
drowsiness
| psychosis
29
Since antipsychotics work by decreasing dopaminergic transmission, it makes sense that levodopa (dopamine agonist) can cause __ effects.
psychosis
30
The unpredictable 'On'-'Off' phenomenon may be more common with __. It is difficult to __ and has been described as "throwing a light switch".
younger neurologic patients
| control with medications
31
*The 'wearing off' effect of levodopa refers to __ (aka decreased 'ON' duration). It is associated with __.
1. reduced effect before end of dosing interval
| 2. disease progression
32
* How can we manage the 'wearing off' effect of levodopa?
1. Modify __
2. Replace __
Modify times of administration, and/or
| Replace with modified-release preparations at the appropriate time
33
* How can we manage levodopa induced dyskinesias?
1. add __ or __
2. replace __
1. add amantadine or dopamine agonists
| 2. replace specific doses with modified-release levodopa (at times of day where dyskinesia is more troublesome)
34
Levodopa dyskinesias are most common at __. They involve Involuntary, uncontrollable twitching, jerking and __ (painful muscle contractions).
Peak doses
| Dystonias
35
*With progression of PD, the response threshold is __ while the dyskinesia threshold is __. This leads to the increase in SEs.
1. increased
| 2. lowered
36
*Dose adjustments may be needed when switching between immediate-release (IR) and controlled-release (CR) forms because __.
–IR to CR : generally __ doses (~25%-50%)
–CR to IR : generally __doses
Dose adjustments may be limited by __.
1. CR dosage forms have lower bioavailability
2. increase
3. decrease
4. available dosage forms
37
*Controlled-release (CR) levodopa formulations are designed to release levodopa/DCI over a longer period of time, around __. They are more useful for __.
4-6h
| stiffness on waking
38
Some administration precautions to note for Sinemet SR?
Do not crush
39
Some administration precautions to note for Sinemet CR?
Do not cut
40
Some administration precautions to note for Madopar HBS?
Do not open capsule
41
Pyridoxine is a co-factor for dopa decarboxylase. Will interactions be expected between levodopa and pyridoxine use in TB patients?
No, as only low doses are used
42
Pyridoxine is a co-factor for dopa decarboxylase. Will interactions be expected between levodopa and pyridoxine use in hematological patients?
Yes, as high potency doses are used
43
*Common anti-emetics such as Metoclopramide and prochlorperazine are __ and will reduce effectiveness of levodopa. The anti-emetic of choice in PD is __.
1. anti-dopaminergic drugs (crosses BBB more)
| 2. domperidone (crosses BBB less)
44
*Antipsychotics i.e. Risperidone have opposite MOA compared to Levodopa and may cause __ or even __.
EPSEs or even inhibit levodopa action
45
For foreign travelers, we should note the interaction between levodopa and __ (drug class not stocked in SG) due to its anti-dopaminergic effects.
Non-selective MAO-I
46
*What are some ergot derivatives of dopamine agonists available in SG?
```
Pergolide
(ergot)
Cabergoline
Bromocriptine
(PECB)
```
47
```
*What are some non-ergot derivatives of dopamine agonists available in SG?
– __
– __
– __ (transdermal)
– __ (SQ)
```
```
(non-ergot)
–Pramipexole
–Ropinirole
–Rotigotine (transdermal)
–Apomorphine (SQ)
(NEPRRA)
```
48
*What are the 3 key clinically important differences between ergot and non-ergot derivatives?
1. Lower F for ergot derived due to extensive 1st pass
2. Higher fibrosis risk for ergot derived
3. Higher Valvular heart disease risk for ergot derived
49
*Compared to Levodopa, Dopamine agonists have a __ and cause less __.
longer half life/duration of action
| less motor complications
50
*Ropinirole is mainly metabolized via __. Dose adjustments should be made for __.
Hepatic route
| hepatic impairment
51
*Pramipexole is mainly excreted via __. Dose adjustments should be made for __.
```
Renal route (excreted unchanged)
renal impairment
```
52
*Dopamine agonists cause similar peripheral dopaminergic side effects as levodopa. They include: __/__ and __. Similar CNS dopaminergic side effects include: __.
1. N/V and Orthostatic hypotension
| 2. Somnolence, day-time sleepiness
53
*Dopamine agonists cause more __ compared to levodopa.
CNS dopaminergic side effects
54
*Dopamine agonists may cause __ as part of its CNS dopaminergic side effects. They are likely to be __.
Hallucinations
| Visual rather than auditory
55
*Dopamine agonists may cause __ as part of its CNS dopaminergic side effects. They may manifest as Gambling, shopping, eating, hypersexuality
compulsive behaviours
56
*Compared to levodopa, __ is a peripheral dopaminergic SE more common for dopamine agonists.
leg edema
57
Among the dopamine agonists, __ has the lowest incidence of postural hypotension.
Ropinirole
58
* Dopamine agonists may cause the following NON-dopaminergic adverse effects, both of which have lower incidence in non-ergot agents.
1. __ (partially reversible on withdrawal)
2. __
1. Fibrosis (Pulmonary, pericardiac, retro-peritoneal)
| 2. Valvular Heart disease
59
*Dopamine agonists may be used as monotherapy in __ and as an adjunct to __ in moderate/severe PD.
young-onset PD
| levodopa
60
Dopamine agonists are less preferred in __ compared to levodopa due to the possibility CNS side effects exacerbating existing CNS insults.
elderly patients
61
*__ and __ are non-ergot derivative dopamine agonists available in sustained release formulations.
Pramipexole and Ropinirole
62
Dostinex contains 0.5mg of __ (the only brand registered in SG) which is commonly used for hyperprolactinemia. Due to the low dose, use in PD is difficult as it would be expensive (many pills required).
Cabergoline
63
*The MAOB-i used for PD treatment in Singapore are __ and __. They are both irreversible inhibitors.
Selegiline and rasagiline
64
In the context of PD, MAOB-I are effective as __ in the early stages of PD because they can __ unlike COMT inhibitors.
monotherapy
| cross BBB
65
*MAOB-i have a short half life but __ which allows for OD/BD dosing.
long duration of action (irreversible inhibitors)
66
*The common dosing for Selegiline is __.
5mg OD/BD
67
*The common dosing for Rasagiline is __. There is no need to dose Rasagiline in the afternoon unlike Selegiline because __.
0.5-2mg OD
| Rasagiline is not metabolized to amphetamines
68
Due to __ metabolism to stimulatory amphetamines, the second dose of Selegiline should be taken __ due to avoid insomnia .
hepatic
| in the afternoon
69
*A key Drug-Drug interaction of MAOB-I are that they may cause __ with SSRIs/SNRIs/TCAs. A __ is recommended to avoid this interaction.
serotonin syndrome
| wash-out period
70
*A key Drug-Food interaction of MAOB-I is __ with __. Patients should be advised to avoid these foods.
Cheese reaction with tyramine rich foods
71
*The improvement in UPRDS scores for MAOB-I is __ compared to dopamine agonist/levodopa.
not as good
72
MAOB-i is commonly used as monotherapy in __ and may be used as an adjunct in __.
early stages of young onset PD
| later stages of PD
73
The antipsychotic of choice in PD patients is __ (avoid self harm/harming others).
Quetiapine
74
Comparing Levodopa vs Dopamine agonists vs MAOB-I, Which of these have the best effect on motor symptoms?
Levodopa
75
Comparing Levodopa vs Dopamine agonists vs MAOB-I, Which of these have the best improvement in ADLs?
Levodopa
76
Comparing Levodopa vs Dopamine agonists vs MAOB-I, Which of these have the most motor complications?
Levodopa
77
Comparing Levodopa vs Dopamine agonists vs MAOB-I, Which of these have the most adverse events?
Dopamine agonists
78
*The only selective and reversible COMT inhibitor available in SG is __. __ is not available in SG and is more for travelers.
Entacapone
| Tolcapone
79
*COMT inhibitors are not effective without __. They should be taken at the same time.
concurrent Levodopa
80
*COMT inhibitors work by __.
increasing the 'ON' time (levodopa duration of action)
81
*Entacapone may cause __ and __ (important to assure patients that it is harmless).
diarrhea and urine discoloration
82
*Due to chelation reactions with __ and __, entacapone should be __.
Iron and calcium
| spaced out 2-4h apart
83
*Entacapone has an interaction with warfarin as it __.
enhances the anti-coagulation effect.
84
*For patients on Entacapone, they should avoid __ and __. Caution should be taken with __.
Non-selective MAOIs
Any catecholamine drugs
Selective MAOA-Is
85
*Can Entacapone be used with these MAO inhibitors?
Non-selective MAO inhibitors?
MAO-A inhibitors?
MAO-B inhibitors?
Non-selective MAO inhibitors: Avoid
MAO-A inhibitors: caution
MAO-B inhibitors: safe
86
*If a PD patient with hepatic impairment is planning to start Entacapone, we should __. LFT monitoring is __.
use with caution
| not required
87
*Entacapone may potentiate __ and cause __ upon initiation. A __ may be required to avoid this.
1. other peripheral dopaminergic SEs (N/V, orthostatic hypotension)
2. dyskinesias
3. levodopa dose reduction (depending on available dosage forms)
88
What is stalevo?
entacapone 200mg + levodopa:carbidopa in 1:4 ratio
89
What is comtan?
entacapone 200mg
90
Compared to entacapone, tolcapone is more __ with a __ duration of action. LFTs are indicated every __ for after initiation of tolcapone.
potent with a longer duration of action
| 2-4wk x 6months
91
*Anticholinergics have limited use in PD because __. In practice, they are primarily used to __.
they usually worsen PD symptoms
| control tremors
92
*The side effects of anticholinergics are:
```
Dry mouth, constipation, urinary retention (Dry as a bone)
Blurred vision (blind as a bat)
Confusion (mad as a hatter)
```
93
Benztropine is rarely used in PD. It has a total PO daily dose of __ and is dosed __ times daily.
2-16mg/day
| at most 2
94
Benzhexol or trihexyphenidyl has a total PO daily dose of __ and is dosed __ times daily.
5-15mg/day
| 3-4
95
Glutamate is associated with __. Glutaminergic activity (activated NMDA receptors) contribute to development and maintenance of __. Therefore, an __ like amantadine can help manage levodopa-induced dyskinesias.
1. neurotoxicity
2. levodopa-induced dyskinesias
3. NMDA antagonist
96
*NMDA antagonists are excreted __ with dose reductions required for patients with __.
renally
| renal impairment
97
*NMDA antagonists are __ and the 2nd dose (if required) should be given in the afternoon and not the evening.
stimulatory
98
*Concurrent use of 2 NMDA antagonists i.e. memantine and amantadine is not recommended as it may lead to__.
over-stimulation and psychosis
99
A patient on amantadine shows you spider web pattern on their skin and is worried. What should you do as a pharmacist?
Inform the patient that the pattern is purely cosmetic and they should not worry
Alternatively, may raise to doctor for assessment.
100
*What is the use of amantadine in PD?
As an adjunct in management of levodopa induced dyskinesias.
101
*What are some adverse effects that amantadine may cause?
```
Nausea
Light headedness
Insomnia
Confusion
Hallucinations
Livedo reticularis
(NLICHL)
```
102
What is the use of apomorphine in PD?
For treatment of motor fluctuations
103
What is the difference between parkinsonism and Parkinson's disease?
Parkinson's disease refers to idiopathic PD (caused by degeneration of dopaminergic neurons) while parkinsonism may be due to a variety of causes.
104
In PD, patients usually present with unilateral symptoms. Compared to PD, vascular parkinsonism (VP) patients __.
usually present with bilateral symptoms
105
In PD, resting tremor is a cardinal symptom. Compared to PD, VP patients __.
usually do not have resting tremor
106
Idiopathic PD has gradual progression, not worsened by any particular event. On the other hand, VP has __.
stepwise progression (i.e. worsened with more CNS insults)
107
In VP, __ are usually present. __ is a risk factor for VP as well.
vascular risk factors (i.e. 3 highs)
| Age
108
In PD, dopaminergic neuronal death in the substantia nigra occurs. However, most cases of VP are __. Therefore, __ is not very effective in management of symptoms in VP.
not caused by infarcts/lesions in the basal ganglia.
| levodopa
109
For drug induced parkinsonism (DIP), __ and __ are risk factors.
increasing age and being female
110
In PD, patients usually present with unilateral symptoms. Compared to PD, DIP patients __.
usually present with bilateral symptoms (symmetrical)
111
Idiopathic PD has gradual progression, not worsened by any particular event. On the other hand, DIP may have __ onset.
acute or subacute
112
PD remains progressive despite treatment. On the other hand, __ may be potentially reversible on treatment.
DIP
113
__ patients usually respond poorly to levodopa.
DIP/VIP
114
Other than PD-like symptoms, what are some other symptoms a DIP patient may present with?
Orofacial dyskineisa and akathisia
115
Of the cardinal symptoms for PD, __ is uncommon while __ is usually manifested in DIP.
resting tremor
| bradykinesia/akinesia
116
*PD is caused by insufficient dopaminergic transmission. Therefore, drugs that __ or __ have a risk of DIP.
reduce dopaminergic transmission or cause dopamine block
117
Some common suspects of DIP include __, __ and __.
Antipsychotics
Cinnarizine
Antiemetics/gastric motility agents (prochlorperazine, metoclopramide)
118
Patients repeating short term courses of __ or __ should be advised to check with their doctors as they may induce DIP.
Cinnarizine
| Antiemetics/gastric motility agents (prochlorperazine, metoclopramide)
119
DIP may unmask existing PD. The course of DIP is variable but onset may occur __ within exposure to offending agent.
~3months
120
*__ and __ may be used to reduce the severity of DIP.
Amantadine and anticholinergics
121
Parkinson Hyperpyrexia Syndrome (PHS) is a rare but fatal condition. It may be caused by:
– changes in __
– provoked by trauma, surgery, and infections;
– may have no apparent trigger.
dopaminergic treatment
122
In severe cases of PHS, there is no response to __ and symptoms deteriorate rapidly, patient becomes progressively more immobile and rigid.
dopaminergic rescue medications
123
*If the cause of PHS is a reduction in dopaminergic medications, we should __ and gradually increase __.
Reinstate previous treatment
| dose of levodopa
124
As PHS patients may be rigid and unable to swallow, non-PO options such as __ patch or __ injection may be used if available. __ and __ are also options that are likely available at most institutions.
Rotigotine
Amantadine
Dantrolene
Bromocriptine
125
Madopar Dispersible is similar to effervescent tablets and is more commonly used for morning doses. (meant to relieve __) It is administered by dropping the tablet in a glass of water to drink. (faster __ = faster __)
morning stiffness on waking
absorption
onset of action
126
*Common DDIs in the context of PD patients will include:
__ and __ (due to risk of EPSEs)
Common __
SSRIs and Dopamine antagonists (due to risk of EPSEs)
| Common anti-emetics
127
What are some problems PD patients may face when it comes to physically using the medications?
1. Hard to __
2. Hard to __
3. __ pills
1. Hard to unscrew caps
2. Hard to pop blister packs
3. Dropping pills
