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PHRM 845 EXAM 3 > PD pharmacotherapy > Flashcards

PD pharmacotherapy Flashcards

1
Q

Motor symptoms

A

Tremor

Bradykinesia (cardinal sign)

Rigidity

Parkinsonian gait

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2
Q

Non-motor symptoms

A

anxiety, depression

constipation

dementia

insomnia

orthostatic hypotension

psychosis/delirium

sexual dysfunction

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3
Q

Assessment of disease

A

Unified Parkinson’s disease rating scale (UPDRS)

Standardized rating scale to assess signs/symptoms of PD

Scale scores from 0-4 to assess 42 domains for PD severity

Higher UPDRS score=worse PD symptoms

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4
Q

Goal of therapy

A

Minimize/manage motor and non-motor symptoms

Maintain high QOL possible

Preserve activities of daily living

Minimize/manage adverse drug reactions

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5
Q

Non-pharmacological therapy

A

Exercise/physical therapy

Nutritional counseling

Occupational therapy

Psychotherapy/ support groups

Speech therapy

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6
Q

Initial treatment

A

1st line:
Rule out drug-induced PD
Dopamine precursor
Dopamine agonists
MAO-B inhibitor

2nd line:
COMT inhibitors
Amantadine

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7
Q

Treatment initiation

A

For most, initiate with Levodopa (dopamine precursor)

Dopamine agonist may be used as initial treatment if age < 60 years and higher risk for dyskinesia

Avoid dopamine agonists as initial treatment if: >70, those with hx of ICD, cognitive impairment, sleepiness, hallucinations

IR>CR

Initiate with lowest effective lowest dose to delay adverse effects

Efficacy with motor symptoms: Levodopa/carbidopa>DA>MAOB-I

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8
Q

Levodopa/carbidopa

A

dopamine precursor

1st line for initial treatment and throughout

gold standard

adjunctive therapy with dopamine agonists and other agents

SE: N/V, LD motor fluctuations/dyskinesias, hallucinations

Starting dose: 25/100 mg CD/LD TID with meals

maintenance frequency can increase as needed (5-6x/day) or switch to CR/XR as needed

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9
Q

Dose-response curves

A

SLIDE 18

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10
Q

Wearing off

A

before next dosing interval, signs of motor symptoms

Increase CD/LD dose or frequency

Add DA agonist, MAO-I, or COMT, XR CD/LD

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11
Q

Freezing

A

inability to move due to insufficient or fluctuating DA levels

Increase CD/LD dose or frequency

Add DA agonist (apomorphine)

Add ODT CD/LD

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12
Q

Delayed onset

A

Therapeutic benefits delayed

Take CD/LD on empty stomach

ODT CD/LD

Avoid CR/XR CD/LD

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13
Q

Peaked-dose dyskinesias

A

involuntary body movement caused by high DA levels

Add Amantadine?

Decrease dose of DA or CD/LD

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14
Q

Pramipexole, Ropinirole, Rotigotine, Apomorphine

A

Non-ergot DA agonists for initial PD tx

Minimize LD motor fluctuations

Ergots used rarely due to toxicity

SE: N/V, ICD, Hallucinations, orthostatic hypotension

Advantages: few motor fluctuations, long-acting formulations

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15
Q

Bromocriptine, Cabergoline

A

Ergot DA agonists

Same stuff as non-ergots

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16
Q

Rasagiline, Selegiline, Safinamide

A

MAO-B inhibitors

1ST line for mild symptoms

2ND line for adjunctive therapy

SE: N/V, HA, Insomnia, hypo/hypertension

Rasagiline: 0.5 mg po qd
Selegiline: 5 mg po BID
Safinamide: 50 mg po qd

Risk of serotonin syndrome with use of serotonergic antidepressants, dextromethorphan, serotonergic opioids

17
Q

Entacapone (CD/LD as Stalevo)

Opicapone

Tolcapone

A

COMT inhibitors

Used in combo to manage symptom fluctuation

SE: N/V, BROWN/ORANGE URINE DISCOLORATION, Hepatotoxicity

In early PD, no benefit of COMT inhibitors with CD/LD compared to CD/LD alone

Entacapone: 200 mg po with each CD/LD dose

Tolcapone 200 mg po TID

Opicapone 50 mg po QHS

18
Q

Benztropine, Trihexyphenidyl

A

Anticholinergics

Management of tremor-dominant symptoms in patients < 65 yo

SE: confusion/dementia, blurry vision, urinary retention, dry mouth, constipation

Benztropine: 0.5 mg po QHS
Trihexyphenidyl 1 mg PO daily

19
Q

Monitoring

A

Evaluate motor symptoms

Assess for SE related to pharmacotherapy

Identify medications which can worsen PD

20
Q

Patient education

A

Stress importance of adherence and timing of medication

Pros/cons of taking medication with food

Report side effects and symptoms to provider

support group

21
Q

Treatment initiation and flow

A

Treatment warranted: non pharm

DA: Contingent: Dop precursor, MAO-B, COMT

Dop precursor: most: DA, MAO-B, COMT

MAO-B: Contingent: DA, dop precursor

22
Q

DA PROS

A

Once daily dosing

Better tolerated by younger patients

Limited motor fluctuations

23
Q

DA CONS

A

Expensive

Less symptomatic benefit compared to CD/LD

Many AE

24
Q

CD/LD PROS

A

GOLD STANDARD

COST

VARIETY OF DOSAGE FORMS

25
Q

CD/LD CONS

A

Motor fluctuations

Dosing frequency can be > 3x/day

26
Q

MAO-B PROS

A

Generally well tolerated

Delays onset of motor fluctuations

27
Q

MAO-B CONS

A

Least effective first line agent against motor fluctuations

Dietary restrictions–> risk of serotonin syndrome

28
Q

Constipation

A

Evaluate for medications causing constipation

Increase fluid intake, physical activity

Stool softener/ laxatives or probiotics

29
Q

Insomnia

A

Non-pharm counseling

Melatonin

AVOID: BENZOS

30
Q

Orthostatic hypotension

A

Non pharm counseling

Midodrine, Droxidopa

Medical equipment to stabalize patients

31
Q

Anxiety/depression

A

Cognitive behavioral therapy

SSRI, SNRI

Avoid: BENZOS

CAUTION: TCA

32
Q

Dementia

A

Cholinesterase inhibitor

Avoid: anticholinergics, benzos, antihistamines, sedatives

33
Q

Psychosis/delirium

A

Reduce PD medication doses

Pimavanserin: antipsychotic for PD

Atypical antipsychotics

AVOID: haloperidol, olanzapine, paliperidone, risperidone

PHRM 845 EXAM 3 (11 decks)

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