Parkinsons

Question 1

Day time sleepiness/sudden onset of sleep in PD

Answer 1

Adjust drug treatment
Modafinil (rv every 12 months)

Question 2

Rapid eye movement sleep behaviour disorder in PD

Answer 2

Clonazepam or melatonin once pharmacological causes have been addressed

Question 3

Sailva drooling

Answer 3

Speech and language first line
Glycopyrronium bromide
Botox

Question 4

Parkinsons disease dementia

Answer 4

Mild-to-moderate PDD: Offer acetylcholinesterase inhibitor (e.g. rivastigmine – licensed for this use).
Severe PDD: Consider acetylcholinesterase inhibitor (unlicensed use).
If not tolerated/contraindicated: Consider memantine hydrochloride (unlicensed).

Question 5

Antipsychotic use in PD

Answer 5

First decrease any dosage that may be causing these symptoms
1st - If no cognitive impairment use quetiapine

2nd - Clozapine

Question 6

Postural hypotension in PD

Answer 6

Rv drug treatment to address any pharmacological cause

Midodrine is first line
Fludrocortisone is an alternative

Question 7

Motor symptoms treatment

Answer 7

If decreasing QOL= Levodopa+ carbidopa or beneserazide

If no effect on QOL= Levodopa or non ergot derived dopamine receptor agonist (pramipexole, ropinirole, rotigotine) or MAOB (rasagiline, selegiline)

Question 8

Patient counselling for antiparkinsonian drugs

Answer 8

Psychotic symptoms
excessive sleepiness
sudden onset of sleep
impulse control disorders

Question 9

Q: What adjuncts can be offered to patients with Parkinson’s who develop motor fluctuations despite optimal levodopa therapy?

Answer 9

A: Non-ergotic dopamine-receptor agonists (pramipexole, ropinirole, rotigotine), MAO-B inhibitors (rasagiline, selegiline), or COMT inhibitors (entacapone, tolcapone).

Question 10

Q: When should ergot-derived dopamine-receptor agonists be considered in Parkinson’s management?

Answer 10

A: Only if symptoms are not adequately controlled with non-ergot-derived dopamine agonists

Question 11

Advanced Parkinson disease treatment

Answer 11

Apomorphine as intermittent injections/continous SC infusion
Can cause n+V - Domperidone

Question 12

Nocturnal akinesia in PD
impaired ability to move in bed during sleep, especially in individuals with Parkinson’s disease (PD) treatment

Answer 12

1st- Levodopa or dopamine receptor agonists

Question 13

When would you give domperidone with apomorphine treatment

Answer 13

Start 2 days before starting apomorphine and discontinue ASAP to reduce N+V

Question 14

Domperidone risks

Answer 14

Need to assess cardiac risk factors and monitor ECG before initiating domperidone due to risk of arrhythmia due to QT prolongation associated with concomitant use of domperidone and apomorphine

Question 15

Key SE of levodopa

Answer 15

Arrythmias
Impulse control
On and off symptoms
Dyskinesia
Sudden onset of sleep
Psychosis

Question 16

Levodopa in preg and BF

Answer 16

Contraindicated

Question 17

Levodopa Interactions

Answer 17

With antihypertensives as can cause hypotensive effect

Question 18

COMT inhibitors + Levodopa interaction

Answer 18

Reduce COMT inhibitor dose by 10-30%

Question 19

ERGOT derivatives dopamine agonists

Answer 19

Bromocriptine
Pregolide
Cabergoline

Question 20

Non ergot derivatives dopamine agonists

Answer 20

Ropinirole
Pramipexole
Rotigotine
Apormorphine

Question 21

Side effects of dopamine agonists

Answer 21

Fibrosis - ECG required
GI upset
Postural hypotension
Hallucinations
Pulmonary oedema
Impulsive disorders- stop and review

Question 22

Advantages of dopamine agonists

Answer 22

• Less off time
• Non-ergot are better tolerated
• Rotigotine can be given as a patch

Question 23

Apomorphine monitoring

Answer 23

Haemolytic anaemia and thrombocytopenia

Initially and 6m after if used with levodopa

Question 24

COMT inhibitor examples

Answer 24

Entacapone
Opicapone
Tolcapone

Question 25

COMT indication

Answer 25

Adjunct to co-beneldopa or co-careldopa in PD with end of dose motor fluctuations

Question 26

COMT side effects

Answer 26

Hepatotoxicity (more common with tolcapone and women) Urine discolouration (reddish-brown) Typical dopaminergic SE

Question 27

Monoamine oxidase type B examples

Answer 27

Selegiline Rasagiline

Question 28

Monoamine oxidase type b indications

Answer 28

PD alone or adjunct to co-beneldopa/ careldropa for end of dose fluctuations

Question 29

Monoamine oxidase type b interaction

Answer 29

Avoid concomitant use with serotonergic drugs - serotonin syndrome

Question 30

Which of levodopa or Dopamine receptor agonist have the more common daytime sleepiness, hallucinations and impulse control disorders

Answer 30

Dopamine receptor

Question 31

IF switching from one levodopa/ co-ben/. co-care

Answer 31

Discontinue for 12 hrs

Question 32

Ketones and dopamine enhancing drugs

Answer 32

Can give false positive urinary ketones

Question 33

Why do we need to avoid abrupt withdrawal from levodopa/co-ben/co-care

Answer 33

Risk of neuroleptic syndrome and rhabdomylosis

Question 34

Why do we use non ergot more than ergot

Answer 34

Ergot have a higher risk of fibrinolysis and cardiac valuopathy. They are less safe and tolerated. Only really use if treatment with non ergot fail

Question 35

Role of ergot/non ergot DPA

Answer 35

PD first line option or first line adjunct in late PD

Question 36

Role of COMT inhibitors

Answer 36

Adjunct to co-ben or co-care in PD with end of dose motor fluctuations

Question 37

Role of MAO-B inhibitors

Answer 37

PD alone or adjunct in co-ben or co-care end of dose motor fluctuations