Therapeutics - Parkinsons Part 2 Flashcards by amanda kastel

sinemet therapy should be started with .5 or 1 tab of 25/100 IR

dose should be increased to ______mg/day over 2-3 weeks

then afterward, increased as needed to _____/day

what is max dose?

increase dose to 300-400mg/day (of levodopa) over 2-3 weeks

then increased as needed to 400-800mg/day

max dose is 2gm/day - but this high isn’t used anymore

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when switching from IR to CR sinemet, what is the dose conversion

increase dose by 10-30%

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important consideration when adding a dopamine agonist or another agent to sinemet

may need to decrease the levodopa dose to decrease side effects!!!!

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what form of sinemet should be used for patients with swallowing difficulties OR for early morning doses in bed (bc dont need to get water)

ODT

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VERY important note for sinemet dosing

timing is very important

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when patients are on sinemet, they may experience motor fluctuations

they may have bad times and good times

what is a method to help sinemet keep working

either take on an empty stomach of with a low protein meal, bc levodopa competes with protein for absorption

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true or false

increased gastric emptying may cause motor fluctuations in PD

FALSE - delayed

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a patient is getting SUBOPTIMAL motor control with monotherapy

what are options

-increase the dose, or give more often
-if on sinemet, add DA agonist
-if on DA agonist, add sinemet
-if on levodopa, can add COMT inhibitor

when increasing dosing, be careful to make sure they can tolerate. also confirm they’re taking doses on empty stomach/without high protein meal

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the “end of dose” effect of sinemet usually occurs around how long after starting treatment?

5 years

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difference between:

-wearing off/end of dose effect
-on-off phenomenon

for the wearing off effect, the motor fluctuations are corellated to the plasma levels

for the on-off phenomenon, fluctuations are NOT related to plasma levels

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3 specific options for “off” or “freezing” episodes

apomorphine
inhaled levodopa
istradefylline

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what is “off dystonia”

like a cramping - when the PD medication is wearing off

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3 drugs that treat off dystonia

botulinum toxin
baclofen
anticholinergics

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if off dystonias are an issue, ____ should be used as the primary treatment and ____ as ancillary treatment

primary - dopamine agonist

ancillary - levodopa

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plan of action if the patient has early morning foot dystonia

give a BEDTIME dose of levodopa CR or a DA agonist

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3 levodopa side effects

nausea
sweating/tachycardia
orthostatic hypotension

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true or false

orthostatic hypotension may be caused by levodopa OR can be from the PD itself

true

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treatment for patients who have nausea from levodopa

-give with a low protein meal if they can’t tolerate an empty tummy

-ondansetron or granisetron

-give extra carbodpa

-(domperisone - investigational)

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medication for a patient who has sweating/tachycardia from levodopa

beta blocker

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jobst stockings

may help orthostatic hypotension either caused by levodopa or from the PD itslef

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3 potential drugs to help the orthostatic hypotension from PD or from levodopa

fludrocortisone
midodrine
droxidopa ($)

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true or false

a low sodium diet can help with orthostatic hypotension

FALSE - high salt or salt tablets

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true or false

elevating the head of the bed can make orthostatic hypotension worse

FALSE - can help

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indication for inhaled levodopa (ONLY)
brand is inbrija

PRN treatment of off episodes in patients who are on sinemet

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what's the drug: adjunctive treatment to sinemet in patients experiencing off episodes. an adenosine A2A receptor antagonist

istradefylline

inhaled levodopa (inbrija) vs istradefylline

both are adjunctives to sinemet for off episodes HOWEVER, inbrija is PRN and istradefylline is NOT - it's for prevention

which class of PD meds is thought to potentially be neuroprotective? how?

dopamine agonists by their levodopa sparing effect

true or false dopamine agonists are metabolized by oxidation

FALSE

_____ decrease the need for higher doses of levodopa

dopamine agonists

true or false dopamine agonists can either be used alone OR in combo with sinemet

TRUE

true or false dopamine agonists show increased risk of dyskinesias

FALSE - decreased risk

true or false dopamine agonists have a narrow TI

false - wide

major advantage of dopamine agonists over sinemet

no competition with dietart amino acids therefore, can be given with a meal to decrease chance of any nausea (for sinemet - had to be a low protein meal if anything)

name 2 oral dopamine agonists and 1 transdermal

oral - pramipexole, ropinirole transdermal - neupro

important dosing notes for the oral dopamine agonists (pramipexole, ropinirole)

START LOW GO SLOW!!!!! - too fast can cause hallucinationas (titrate weekly) also when stopping, taper down to avoid dopamine withdrawal

advantage of neupro (rotigotine) over the oral dopamine agonists

less GI effects

true or false like the oral dopamine agonists, neupro should also be titrated slowly

true

true or false dopamine agonists cannot be given with meals

FALSE - they should be to avoid nausea

can dopamine agonists cause impulse control disorders?

yes

true or false dopamine agonists do not cause CNS effects

false - they do can cause confusion, hallucinations, and sleep attacks (randomly fall sleep)

true or false dopamine agonists cannot cause orthostatic hypotension

false - they can patients should be counseled to change positions SLOWLY

counseling for dopamine agonists

-take with meals to decrease nausea -orthostasis - change positions slowly -CNS effects!

which med is like "oil for the tin man" meaning the patient is in an off episode and frozen and can't actually inject themselves - they need someone else to do it

apomorphine

route administration apomorphine

subq - like an insulin pen a new SQ continuous infusion just came out a few months ago too

counseling for apomorphine continuous SQ infusion

change site and cartridge every day infuse via pump in thigh/abdomen/lower back

MOA of COMT inhibitors

more levodopa is converted to dopamine bc COMT metabolizes levodopa both peripherally and centrally --- these drugs block this metabolism

3 COMT inhibitors

tolcapone entacapone opicapone

true or false tolcapone is considered very last line for PD

TRUE causes liver damage

use for entacapone any advantage over tolcapone?

for patients who HAVE SYMPTOMS at end of dose wearing off as an ADJUNT TO SINEMET!

***ENTACAPONE SHOULD NEVER BE GIVEN WITHOUT ________

levodopa!!! bc entacapone inhibitrs COMT in the gut!

what is the name of the combo product of sinemet + entacapone

stalevo

entacapone ADR

dopaminergic effects ( bc increased dopamine) ND urine discolaration to brown-orange

advantage of entacapone over tolcapone

no liver dysfunction reported

to avoid excess dopaminergic effects of entacapone, what may need to be done?

may need to decrease the dose of levodopa

what meds should entacapone NOT be given with

nonselective MAO inhibitors all meds metabolized by COMT s be should be avoided (otherwise toxicity) -- epi, NE, dopamine, dobutamine, isoproterenol, bitoterol

opicapone administration instructions

DO NOT EAT 1 HOURS BEFORE OT 1 HOUR AFTER THE DOSE (over 99% protein bound) give at bedtime

role of opicapone in PD

adjunctive to sinemet in patients experiencing off episodes

if a patient is experiencing hallucinations on PD meds, what is done? what are the 3 options that may be used and are safe

decrease the dose as much as possible, dc offending meds clozapine, quetiapine, and pimavanserin are safe

options for depression for PD patients

either TCA or SSRI BUT avoid SSRI when on MAO-B inhibitor

if a PD patient is getting nightmares what should be done

give the last dose EARLY in the evening or decrease the night time dose

PD patient is experiencing daytime drowsiness what should be done

can try caffeine or selegiline (amphetamine-like matabolite)

if a PD patient is experiencing sleep problems bc of their PD symptoms, what can be done

-long acting dopamine agonist or a bedtime dose of levodopa

"atypical antipsychotic indicated for the treatment of hallucinations and delusions associated with PD psychosis"

pimavanserin

true or false pimavanserin is indicated for PD psychosis and dementia-related psychosis

FALSE - only PD psychosis

MOA pimavanserin

5HT2A inverse agonist

____ may be used to treat tremors that are unresponsive to other therapies (unapproved use)

beta blockers

name for vitamin E

alpha-tocopherol

vitamin E's role in PD

does not slow progression 1 study found that dietary vitamin E may decrease the risk of PD

COQ10 role in PD

some evidence of slower progression with high doses

deep brain stimulation is surgery that can treat PD in what patients should it be avoided? in what patients does it work best in?

avoid in pts wiht cognitive impairment works best in pts who have at least partial response to medications

PD pt has sialorrhea (drool) what 3 things can be used

botox sublingual atropine glycopyrrolate

PD patient has seborrhea what can be used

selenium or coal tar shampoo

Therapeutics - Parkinsons Part 2 Flashcards

(73 cards)