Parkinson's tx

Question 1

PD disease progression

Answer 1

-over 5-10 years w inc in motor sx
-cognitive sx after several years
-~15 year life expectancy after dx

Question 2

PD clinical presentation

Answer 2

-tremor
-bradykinesia
-rigidit
-gait
-anxiety/depression
-constipation
-dementia
-insomnia
-hypotension
-psychosis/delirium
-sexual dysfunction

Question 3

Goals of PD therapy

Answer 3

1. minimize sx
2. QOL
3. ADLs
4. minimize se

Question 4

Non-pharmacologic tx of PD

Answer 4

-exercise/PT
-nutrition
-occupationaly therapy
-psych and speech therapy

Question 5

PD tx

Answer 5

1. rule out drug-induced
2. Dopamine precursor
3. DA agonist
4. MAO-B inhibitor
5. COMT inhibitor
6. Amantadine

Question 6

First line tx of PD

Answer 6

-rule out drug-induced
-dopamine precursor
-dopamine agonists
-MAO-B inhibitor

Question 7

2nd line tx of PD

Answer 7

-COMT inhibitors
-Amantadine

Question 8

Treatment initiation

Answer 8

-Levodopa for most
-can use dopamine agonist if <60 and higher risk for dyskinesia (risk of dyskinesia inc w time)
-IR > CR
-start low
-LDOPA > DA > MAOB for motor sx

Question 9

AVOID DA agonists if

Answer 9

->70
-hx of ICD
-cognitive impairment
-xs daytime sleepiness
-hallucinationa

Question 10

PD meds w better efficacy for motor sx

Answer 10

-LDOPA > DA > MAO-B

Question 11

LDOPA

Answer 11

-gold standard
-N/V
-LD motor fluctuations/dyskinesia
-hallucinations

Question 12

LDOPA clinical (or duodenal gel)

Answer 12

-inc absorption w empty stomach
-food dec nausea
-25/100mg PO BID-TID wf to start
-can inc freq as needed (5-6x day!)
-titrate to weigh risk v benefit

Question 13

Patterns of motor fluctuations in PD

Answer 13

-duration of LDOPA concentration shortens w progression of disease
-doses go over threshold = dyskinesia

Question 14

LD motor fluctuations

Answer 14

-wearing off: sx before next dose
-freezing (inability to move bc DA levels)
-delayed onset (benefits delayed)
-peak-dose dyskinesias (involuntary movements bc dose too high)

Question 15

Dopamine agonist drugs

Answer 15

-Non-ergot
-Pramipexole (Mirapex®)
-Ropinirole (Requip®)
-Rotigotine (Neupro®)
-Apomorphine (Apokyn®
injection and SL film)

-Ergot (rarely use bc toxicity)
-Bromocriptine
(Parlodel®)
-Cabergoline (Dostinex®)

Question 16

non-ergot Dopamine agonist clinical

Answer 16

-first line for initial tx
-minimize LD motor fluctuations
-long-acting formulations
-N/V
-suddeen onset sleep
-hallucinations
-impulse control disorder (ICD)
-Edema
-orthostatic hypotension

Question 17

MAO-B inhibitors

Answer 17

-first line mild sx
-second line for adj
-motor and depression management

Question 18

MAO-B inhibitors side effects

Answer 18

-N/V
-HA
-insomnia (selegiline)
-Hypo/Hyper tension
-avoid tyramine rich foods
-risk of serotonin syndrome (sertonergic antidepressants, dextromethorphan, serotonergic opioids)

Question 19

MAO-B clinical

Answer 19

-once/twice daily dosing
-avoid tyramine-rich foods

Question 20

COMT inhibitor side effects

Answer 20

-N/V
-brown/orange urine!! (entacapone)
-hepatotoxicity (toclcapone use limiting side effect)

Question 21

COMT clinical

Answer 21

-prob no benefit in early stage PD

Question 22

Anticholinergic drugs

Answer 22

-benztropine
-trihexyphenidyl

Question 23

anticholinergic side effects

Answer 23

-confusion
-blurry vision
-urinary retention
-dry mouth
-constipation

-AVOID if >65 yo

Question 24

Amatadine use

Answer 24

-manage LD motor fluctuations
-rarely monotherapy
-reserved for CD/LD peak dose dyskinesias

Question 25

Amatadine side effects

Answer 25

-insomnia -confusion -hallucination -livedo reticularis -use is limited bc SE

Question 26

Medications that can worsen PD:

Answer 26

Dopamine antagonists: antipsychotics, metoclopramide, prochlorperazine, promethazine

Question 27

Pros of dopamine agonists

Answer 27

-once daily dosing -better tolerated by young pt -limited motor fluctuations

Question 28

Dopamine agonist cons

Answer 28

-$$ -less sx benefit than CD/LD -many adverse effects

Question 29

Who is treated w dopamine agonists

Answer 29

-age < 60 and higher risk of dyskinesia -avoid in >70, ICD hx, cognitive impairment, drowsiness, hallucinations

Question 30

MAO-B pros

Answer 30

-well tolerated -delays onset of motor fluctuations

Question 31

MAO-B cons

Answer 31

-least effective 1st line agent against motor sx -dietary restrictions = risk of serotonin syndrome

Question 32

MAO-B for who

Answer 32

-minor sx -higher risk of motor fluctuations

Question 33

Wearing off tx

Answer 33

-inc CD/LC dose or frew -add DA, MAO, COMT -XR CD/LD

Question 34

freezing tx

Answer 34

-inc CD/LD dose/freq -add DA agonist (apomorphine) -add ODT CD/LD

Question 35

delayed onset tx

Answer 35

-take CD/LD on empty stomach -ODT CD/LD -avoid CR/XR CD/LD

Question 36

Peak-dose dyskinesia tx

Answer 36

-add amantadine -dec dose of DA or CD/LD

Question 37

Deep brain stimulation

Answer 37

-surgical tx if motor fluctuations not managed -risk infection -neurotransmtter on clavivle

Question 38

Constipation in PD tx

Answer 38

-eval drug-induced -inc fluids and activity -laxatives

Question 39

Insomnia in PD tx

Answer 39

-melatonin -AVOID benzos (-pams)

Question 40

Orthostatic hypotension in PD tx

Answer 40

-midodrine, droxidopa -med equipment

Question 41

Anxiety/depression tx in PD

Answer 41

-CBT -SSRI -SNRI -AVOID benzo -caution tricyclic antidepressants

Question 42

Dementia in PD tx

Answer 42

-cholinesterase inhibitor -AVOID: anticholinergics, benzos, antihistamines, sedatives

Question 43

Psychosis/delirium tx in PD

Answer 43

-reduce PD med dose -pimavanserin (newish antipsychotic for psychosis -atypical antipsychotics (clozapine, quetiapine) -AVOID: haloperidol, olanzapine, paliperidone, risperidone