Parkinsons

Question 1

Levodopa (L-DOPA) (Dopar)

Answer 1

C: Dopamine precursor
M: Oral, absorbed in small bowel
T: Given with carbidopa; first-line treatment for Parkinson’s unless patient is young (want to delay as long as possible)
SE: Hallucinations, dyskinesias; on-off phenomenon, neuroleptic malignant syndrome (NMS)*, psychosis possible with chronic use** Nausea/GI distress, hypotension, dizziness
MISC: Given with carbidopa; may accelerate PD progression; relatively short half-life (3 hours)

Question 2

Carbidopa (Lodosyn)

Answer 2

C: Aromatic amino acid decarboxylase inhibitor
M: Inhibits peripheral conversion of L-DOPA to dopamine; does not cross BBB
T: Parkinson’s (given with Levadopa)
SE: Dyskinesias, on-off phenomenon, neuroleptic malignant syndrome (NMS), psychosis possible with chronic use**
MISC: MAO-A inhibitors are contraindicated (except MAO-B, which only hits DA)

Question 3

Bromocriptine (Parlodel)

Answer 3

C: Ergot derivative
M: D2 agonist, D1 antagonist
T: Mild Parkinson’s; DA agonism in NMS; hyperprolactinemia
SE: Pleural effusions, cough, shortness of breath, pulmonary fibrosis** Peripheral DA-like effects
MISC: Must be titrated slowly due to hypotension

Question 4

Pergolide (Permax)

Answer 4

C: Ergot derivative
M: –
T: No longer used for Parkinson’s
SE: Cardiac valve regurgitation; pleural effusions, cough, shortness of breath, pulmonary fibrosis** Peripheral DA-like effects
MISC: Must be titrated slowly due to hypotension

Question 5

Pramipexole (Mirapex)

Answer 5

C: Non-ergot DA receptor agonist
M: Selective D2 agonist
T: Mild Parkinson’s (first-line); to delay L-dopa treatment, usually in combination with ropinorole
SE: More acute: psychosis, nausea/GI, edema, compulsive behavior (nucleus accumbens, D3)**
MISC: Less effective with motor symptoms of PD

Question 6

Ropinorole (Requip)

Answer 6

C: Non-ergot DA receptor agonist
M: Selective D2 agonist
T: Mild Parkinson’s; restless leg syndrome
SE: More acute: psychosis, nausea/GI, edema, daytime sleep attacks**
MISC: Less effective with motor symptoms of PD

Question 7

Rotigotine (Neupro)

Answer 7

C: Non-ergot DA receptor agonist
M: Selective D2 agonist
T: Mild Parkinson’s; restless leg syndrome
SE: More acute: psychosis, nausea/GI, edema**
MISC: Transdermal patch; less effective with motor symptoms of PD

Question 8

Apomorphine (Apokyn)

Answer 8

C: Non-ergot DA receptor agonist
M: –
T: Rescue therapy for ‘off’ periods (immobility)
SE: Psychosis, drowsiness, hypersexuality (increase in erections); emesis (pre-administer trimethobenzamide or domiperidone); hypotension with serotonin receptor antagonists** Peripheral DA effects
MISC: Injectable only; serotonin receptor antagonists contraindicated (e.g., ondansetron)

Question 9

Entacapone (Comtan)

Answer 9

C: COMT inhibitor
M: Prevents breakdown of DA
T: Prolong half-life of levodopa, reduce ‘off’ time; primarily works peripherally
SE: Increase in dyskinesias, diarrhea, urine discoloration** DA side effects
MISC: Short-acting (2 hours)

Question 10

Tolcapone (Tasmar)

Answer 10

C: COMT inhibitor
M: Prevents breakdown of DA
T: Prolong half-life of levodopa, reduce ‘off’ time; primarily works peripherally
SE: Fatal hepatotoxicity (use only if entacapone fails), increase in dyskinesias, diarrhea (worse than entacapone), urine discoloration** DA side effects
MISC: Short-acting (2 hours)

Question 11

Selegiline (Eldepryl)

Answer 11

C: MAO-B inhibitor
M: Prevents breakdown of DA
T: Mild early Parkinson’s (monotherapy); may delay onset of levodopa therapy
SE: Hypotension, GI distress, dyskinesia, psychosis** Nausea, vomiting
MISC: Antidote to environmental toxins; contraindications: decongestants, dextromethorphan, St. John’s wort, analgesics, methadone, tramadol, propoxyphene; caution with SSRIs, MAO-A inhibitors

Question 12

Rasagiline (Azilect)

Answer 12

C: MAO-B inhibitor
M: Prevents breakdown of DA
T: Mild early Parkinson’s (monotherapy); may delay onset of levodopa therapy; also, as an adjunct with levodopa (reduces ‘off’ time)
SE: Hypotension, GI distress, dyskinesia, psychosis** Nausea, vomiting
MISC: Contraindications: decongestants, dextromethorphan, St. John’s wort, analgesics, methadone, tramadol, propoxyphene; caution with SSRIs, MAO-A inhibitors

Question 13

Benztropine (Cogentin)

Answer 13

C: Anticholinergics
M: –
T: Tremor and drooling in Parkinson’s, and really only used if drooling is a major problem (otherwise, very bad mental symptoms)
SE: Confusion, impaired memory, hallucinations** Typical anticholinergic (dry mouth, etc)
MISC: Contraindicated in demented Parkinson’s; abrupt discontinuation exacerbates symptoms

Question 14

Biperiden (Akineton)

Answer 14

C: Anticholinergics
M: –
T: Tremor and drooling in Parkinson’s, and really only used if drooling is a major problem (otherwise, very bad mental symptoms)
SE: Confusion, impaired memory, hallucinations** Typical anticholinergic (dry mouth, etc)
MISC: Contraindicated in demented Parkinson’s; abrupt discontinuation exacerbates symptoms

Question 15

Trihexyphenidyl (Artane)

Answer 15

C: Anticholinergics
M:–
T: Tremor and drooling in Parkinson’s, and really only used if drooling is a major problem (otherwise, very bad mental symptoms)
SE: Confusion, impaired memory, hallucinations** Typical anticholinergic (dry mouth, etc)
MISC: Contraindicated in demented Parkinson’s; abrupt discontinuation exacerbates symptoms

Question 16

Procyclidine (Kemadrin)

Answer 16

C: Anticholinergics
M: –
T: Tremor and drooling in Parkinson’s, and really only used if drooling is a major problem (otherwise, very bad mental symptoms)
SE: Confusion, impaired memory, hallucinations** Typical anticholinergic (dry mouth, etc)
MISC: Contraindicated in demented Parkinson’s; abrupt discontinuation exacerbates symptoms

Question 17

Ethopropazine (Parsidol)

Answer 17

C: Anticholinergics
M: –
T: Tremor and drooling in Parkinson’s, and really only used if drooling is a major problem (otherwise, very bad mental symptoms)
SE: Confusion, impaired memory, hallucinations** Typical anticholinergic (dry mouth, etc)
MISC: Contraindicated in demented Parkinson’s; abrupt discontinuation exacerbates symptoms

Question 18

Amantadine (Symmetrel)

Answer 18

C: Anti-viral
M: Dopaminergic, anticholinergic, anti-NMDA
T: Mild early Parkinson’s (2nd-line); best as an adjunct to levodopa/carbidopa for long-term treatment; movement disorders in Huntingtons; only adjunct that reduces dyskinesias
SE: DA side effects, edema, psychosis, NMS upon withdrawal**
MISC: Excreted unchanged in urine (renal dysfunction requires lower dose); contraindicated in elderly with dementia (anticholinergic effects)

Question 19

Deep brain stimulation

Answer 19

C: Surgery
M: Hits subthalamic nucleus
T: Treatment for motor fluctuations or dyskinesias refractory to other medications; reduces ‘off’ time, may reduce levodopa dosage
SE: Fatal intracerebral hemorrhage, cognitive impairment**
MISC: Patients must still be sensitive to levodopa therapy (or they aren’t a candidate)

Question 20

Test Card

Answer 20

C:
M:
T:
SE:
MISC: