Pharmaceutical Care of Parkinson's Disease

Question 1

What are the main symptoms?

Answer 1

Bradykinesia
Rigidity
Tremor

Question 2

What are the other symptoms?

Answer 2

Postural instability
Sleep problems
Freezing of gait - inability to continue locomotion
Speech problems
Swallowing problems
Mental health

Question 3

What is postural hypotension?

Answer 3

Fall in blood pressure of at least 20 systolic + 10 diastolic

Question 4

What symptoms are associated with postural hypotension?

Answer 4

Light-headedness
Visual blurring
Dizziness
Fatigue
Weakness

Question 5

What is PD diagnosis?

Answer 5

Many other conditions mimic PD
= refer to specialist

Question 6

What are the complications with PD?

Answer 6

Communication
Attitudes to drug therapy
Family/carer needs
Non-motor symptoms

Question 7

What is the disease complication?

Answer 7

Deterioration of quality of speech
= difficult to express emotion

Question 8

What is the attitudes to drug therapy complication?

Answer 8

Medication can take time to work

Question 9

What is the family/carer needs complication?

Answer 9

Difficult watching their family struggle
Changes in lifestyle for carer

Question 10

What is the non-motor symptoms complication?

Answer 10

Distracted, diminished attention

Question 11

What does the choice of drug depend on?

Answer 11

Effectiveness + adverse effects of drugs
Patient comorbidities
Patient response to the drug
Clinical experience
Patient preference

Question 12

What are you managing in the early disease?

Answer 12

Functional disability

Question 13

What are you managing in the later disease?

Answer 13

Motor complications

Question 14

What increases the availability of dopamine to brain?

Answer 14

Decarboxylase inhibitor
COMT inhibitors

Question 15

What decreases the breakdown of dopamine?

Answer 15

MAOb inhibitors
COMT inhibitors

Question 16

What replaces the post-synaptic dopamine stimulation?

Answer 16

DR2 agonists

Question 17

What is the 1st line (1) treatment of early PD?

Answer 17

Levodopa + dopa decarboxylase inhibitor

Question 18

What is the side effect of Levodopa + dopa decarboxylase inhibitor?

Answer 18

Nausea + vomiting

Question 19

What is nausea + vomiting managed by?

Answer 19

Domperidone
= DA receptor antagonist BUT doesn’t cross BBB
= decreased side effects

Question 20

What is the 1st line (2) treatment for early PD?

Answer 20

Oral/transdermal dopamine agonist

Question 21

How do the oral/transdermal dopamine agonist work?

Answer 21

Bind directly post-synaptic dopamine receptor
Combined with Levodopa
Mimic effect of dopamine
Improve motor symptoms

Question 22

What can oral/transdermal dopamine agonists be classified?

Answer 22

Ergot derived = older generation
Non-ergot derived

Question 23

What is an example of ergot derived?

Answer 23

Cabergoline

Question 24

What is the risk with ergot?

Answer 24

Cardiac valvulopathy
Pleural fibrosis - thickening of membrane

Question 25

What is an example of non-ergot derived?

Answer 25

Ropinirole Rotigotine

Question 26

What are the side effects of dopamine agonists?

Answer 26

Impulse control disorders - eg. gambling Daytime drowsiness Peripheral oedema Nausea, dizziness, hallucinations + constipation

Question 27

What is the 1st line (3) treatment of early PD?

Answer 27

MAOb

Question 28

What is an example of MAOb?

Answer 28

Rasagiline Selegiline

Question 29

What is safer out of Rasagiline + Selegiline?

Answer 29

Rasagiline = Selegiline is converted to amphetamine derivatives = sleeping disorders

Question 30

What is NOT used as 1st line for treatment of PD?

Answer 30

Anticholinergic drugs Beta-blockers Amantadine

Question 31

How does anticholinergic drugs work for PD?

Answer 31

Reduce effects of cholinergic excess = some relief of tremor + rigidity

Question 32

What is the example of anticholinergic drug?

Answer 32

Benztropine Biperiden

Question 33

What are the side effects of anticholinergics?

Answer 33

Dry mouth Blurred vision Constipation Confusion Hallucinations

Question 34

What is Amantadine?

Answer 34

Weak dopamine agonist of NMDA-type glutamate receptor

Question 35

How can Amantadine be used?

Answer 35

With Levodopa = improve muscle control + reduce stiffness

Question 36

How are beta-blockers used?

Answer 36

Treatment of tremor

Question 37

What is an example of beta blocker?

Answer 37

Propranolol

Question 38

What are the treatment for non-motor symptoms of PD?

Answer 38

Antidepressants for depression Laxatives NSAIDs for pain-frozen shoulders Benzodiazepines for REM-sleep disorder Fludrocortisone for postural hypotension

Question 39

What are the symptoms of later PD?

Answer 39

Physical symptoms NOT controlled by medication Medication side effects End of dose deterioration function Dyskinesia Freezing

Question 40

What drugs are used to manage later PD?

Answer 40

Levodopa + dopa decarboxylase inhibitor Oral/transdermal dopamine agonist MAOb inhibitor COMT inhibitors Amantadine Apomorphine

Question 41

What is Levodopa used to treat? Later

Answer 41

Postural Freezing

Question 42

What is Apomorphine? Later

Answer 42

Dopamine agonist = non-ergot

Question 43

How is Apomorphine delivered?

Answer 43

Injections

Question 44

What are the side effects of Apomorphine?

Answer 44

Confusion Hallucinations

Question 45

What are MAOb inhibitors used for? Later

Answer 45

Reduce motor fluctuations

Question 46

What should COMT inhibitors be combined with?

Answer 46

Levodopa Carbidopa

Question 47

What is an example of COMT inhibitors?

Answer 47

Tolcapone Entacapone

Question 48

What is Tolcapone associated with?

Answer 48

Fatal hepatic toxicity = mandatory liver function tests

Question 49

What should be done with PD drugs?

Answer 49

Do NOT withdraw them suddenly = avoid potential acute akinesia (loss of voluntary movement)