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Neuro Quiz 6 > Treatment of Parkinson's Disease > Flashcards

Treatment of Parkinson's Disease Flashcards

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1
Q

What is used to stage parkinson’s disease?

A

Hoehn and Yahr staging

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2
Q

Stage 0

A

No clinical signs or symptoms

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3
Q

Stage 1

A

One-sided involvement

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4
Q

Stage 2

A

Bilateral involvement

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5
Q

Stage 3

A

Bilateral involvement with mild postural abnormalities or history of poor balance and falls

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6
Q

Stage 4

A

Bilateral involvement with postural instability

Tremor is eclipsed by advancing bradykinesia and rigidity

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7
Q

Stage 5

A

Severe, advanced
Cannot stand or walk
Cognitive impairment
GI motility is affected

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8
Q

Primary Symptoms

A

Bradykinesia
Postural abnormalities
Tremor
Muscle rigidity

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9
Q

Functional Scales for Evaluation

A

ADL and IADLs

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10
Q

Gait and balance assessment

A

Tinetti

  • Gait is observed through 10 foot walk (swinging, step pattern, etc)
  • Balance is score through a series of commands (sit/stand, etc)
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11
Q

Movement Disorder Assessment

A

AIMS- can also be used for drug-induced PD side effects

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12
Q

Cognitive, Mood and Behavior Assessment

A

GDS, Cornell, Neuropschiatry inventory

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13
Q

Overall PD assessment

A

UPDRS (unified PD risk scale)

- GOLD standard

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14
Q

Selegiline use, dose, class, titration

A 
Neuroprotective and prevent early symptoms
MOAB inhibitor
5 mg BID
(RR, disintegrating tablets, patch)
Tablet is titrated after 6 weeks
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15
Q

Selegiline side effects, CI, precautions, drug/food interactions

A

All CI with meperidine, methadone and MAOI
Patch and tablet: muscle relaxants (end in zaprine)
Patch: antidepressants, decongestants, tyramine food
SE: hypertensive crisis

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16
Q

Selegiline Monitoring

A

PD symptoms
BP
Mood

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17
Q

Rasagiline use, dose, class, titration

A

Prevention
MAOi
Mono (1 mg QD) or adjunct (0.5 mg QD)
No real titration

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18
Q

Rasagiline CI, precautions, side effects, drug/food interactions

A

CI: muscle relaxants, dextromethorphan, meperidine, methadone, tramadol MAOIs
Caution: antidepressants, melanoma, hepatic disease, 1A2 substrates
SE: orthostatic hypotension, HTN, GI, RASH, headache, vivid dreams
Food: Tyramine

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19
Q

Rasagiline Monitoring

A

Parkinson’s symptoms
BP
Skin

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20
Q

Alpha tocopherol dosing and MOA

A

Vitamin E
1000 IU BID
Antioxidant - decrease ROS on DA neurons

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21
Q

DATATOP Results

A

Selegiline is not neuroprotective, but it does allow delay in levodopa therapy (good for early symptoms)
Vitamin E had no effect

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22
Q

Early Treatment: Monotherapy Options

A
  1. MAOB inhibitors (selegiline/rasagiline)
  2. Dopamine replacement (levodopa/carbidopa)
  3. DA agonists (ropinerole, pramipexole, rotigotine patch)
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23
Q

Minimum Daily Dose of Carbidopa

A

75 mg

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24
Q

Levodopa/Carbidopa

A

Sinemet or Sinemet CR - extended release

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25
``` Daily dose of Levodopa A) 300-400 B) 500-600 C) 700-800 D) 900-1000 ```
Sinemet CR Regimen A) 50/200 mg 1 tablet BID B) 50/200 mg 1 tab TID C) 50/200 mg 4 tablets TID or in combo with 25/100 mg form D)50/200 mg 5 tablets TID or in combo with 25/100 mg form
26
Sinemet dose, titration
25/100 BID or TID with 4 hours between CR doses | Max 200/2000 mg/day
27
Sinemet CI, precautions and drug/food interaction
CI: narrow angle glaucoma, malignant melanoma, skin conditions Caution: MI, arrhythmias, asthma, wide angle glaucoma, PUD Drug: Pheytoin, BZD, TCA, Haldol, methyldopa, antacids, MAOI Food- PROTEIN***
28
Sinement SE
Orhtostatic hypotension, arrhythmias, anxiety, confusion, N/V, blurred vision
29
Sinemet Monitoring
PD symptoms BP Mental Sleep (insomnia or vivid dreams)
30
Pramipexole brand, dose, titration
Mirapex 0.125 mg TID Up to 0.5 mg TID Titrate Qweekly
31
Ropinerole brand, dose, titration
Requip 0.25 mg TID Up 0.25 mg TID Titrate Qweekly
32
Rotigotine Patch brand, dose, titration
Neupro 2 mg transdermally Q24H Up 2 mg/24 hr Qweekly Max of 6 mg/24H
33
Dopamine Agonist CI, precautions, AD, drug/food interactions
CI: hypersensitivity SE: BP fluctuations, arrhythmias, dizziness, sedation, hallucinations Interactions: metoclopramide, haldol, reserpine, methyldopa, birthcontrol and smoking
34
Dopamine Agonists Monitoring
PK symptoms BP Mental Sleep/wake
35
Anticholinergic Drugs
Diphenhydramine Benztropine Trihexyphenidyl
36
Anticholinergic Drugs Use and SE
Tremor only usually in young patients SE: dry mouth, blurred vision, constipation, sedation and cognitive impairment TREAT SYMPTOMS NOT THE DISEASE
37
Diphenhydramine Brand
Benadryl
38
Benztropine Brand
Cogentin
39
Trihexyphenidyl Brand
Artane
40
Amantadine brand class, use, side effects
Symmetrel NMDA receptor antagonist Primarily tremor, mild symptoms Not in older pts due to renal elimination and CNS effects SE: dizziness, sedation confusion, vivid dreams, delirium
41
DA replacement + Selegiline or Rasagiline
Selegiline: extends the interval of levodopa and can actually lead to a 25% reduction in dose Rasagiline: gives an extra hour of "on" time
42
DA replacement + DA agonists
DA agonists improve the response to levodopa and decrease "wearing off" and "freezing" (motor complications)
43
DA replacement + DA agonist + COMT inhibitor
COMT- Extends the duration of levodopa and can reduce the dose so good for motor complications
44
COMT drugs
Entacapone | Tolcapone
45
Entacapone brand, dose, titration
Comtam 200 mg with each levodopa dose Up to 1600 mg/day
46
Tolcapone brand, dose, titration, special monitoring
Tasmar 100 mg TID Up to 400 mg TID LFTs: Baseline, Q2wks for first year, Q4wks, for next 6 months, and then Q8wks
47
Entacapone CI, precautions, SE and drug/food interactions
CI: Hypersensitivity SE: dyskinesia, hallucination and hyperactivity Drugs: Ampicillin, Apomorphine, Erythromycin, Methyldopa, NE, RIfampin, Venlafaxine
48
Tolcapone CI, precautions, SE and drug/food interactions
CI: Rhabdomyolysis and hepatic disease SE: confusion, dyskinesia, hallucinations, orthostatic hypotension Drugs: Apomorphine, methyldopa, etc
49
COMT inhibitor Monitoring
PK symptoms BP Mental
50
Apomorphine MOA/Use, Dose, titration
Dopamine agonist!! SQ to help reduce motor fluctuations and reduce "off" time TEST DOSE REQUIRED- 0.2 mL SQ test dose and then initial dose of 0.2 MAX of 2 mL Titration: test dose of 0.4 mL give 0.3 mL dose, test dose 0.3 mL give 0.2 mL
51
Apomorphine CI, cautions, SE
CI: 5HT antagoniss (ondansetron) Caution: CV and cerebrovascular disease SE: HypOtension, angina, MI, priapism, prolong QT
52
Apomorphine Monitoring
BP at pre-dose, 20, 40 and 60 minutes after dose
53
Peak Dose Treatment
RR --> CR | or CR --> RR with more frequent doses
54
Dystonia define and treatment
Twisting at trunk limbs, head or neck | Baclofen
55
Dyskinesia treatment
Partial DA agonists (terguride)
56
Delayed onset treatment
Add RR at the beginning of the dosing interval if on CR Try crushed or liquid Administer on an epty stomach
57
Wearing off treatment
Switch to CR or shorten interval | Try selegiline or rasagiline, DA agonists or COMT inhibitors
58
Freezing treatment
Increase levodopa/carbidopa Add DA agonists Add Rasagiline or entacapone
59
Random fluctuations treatment
DA agonist or if that doesnt cause predictable effects, drug holiday
60
Drug resistant periods treatment
Increase levodopa/carbidopa | Reassess administration technique
61
Myoclonus define and treatment
Involuntary jerky movements during sleep Decrease nightime levodopa/carbidopa Clonazepam QHS Ropinerole is approved for RLS
62
Akathesia Treatment
Antianxiety options (lorazepam or propranolol)
63
Control confounding variables through
One change at a time Be mindful of timeline for changes Include titration and/or taper of doses Rule out other meds and factors (diet)
64
Make your assessments as objective as possible through
Same individual interviews Standardized assessments Document of your observation
65
Periodically reassess and retry, why?
PK is a progressive disease and things change so what didn't work early could work now
66
Fall Factors to Modulate
Environmental factors (trips/fall hazards) Psychoactive meds (antipsychotics, BZD, antidepressants) Inappropriate meds (anticholinergics, sedative, muscle relaxants) Orthostatic hypotension Other disease states Poor vision Incontinence
67
Cognitive impairment
Signs of Alzheimer's--like symptoms in early stage PD could indicate a different dementia Dementia with PD can be treated with rivastigmine (exelon)
68
Interventions for mood and behavioral disturbances
Examine current treatment regimen (dopaminergic regimen = cause?) Adjunct therapy if ABSOLUTELY necessary (benefit outweigh the risk_
69
Atypical agents in PD
Quietiapine or clozapine for hallucination or psychosis
70
Hallmarks of Dementia with Lewy Bodies
Fluctuating cognitive status Spontaneous parkinsonism Visual hallucinations
71
Dementia with Lewy Bodies Treatment
cholinesterase inhibitor or memantine for cognitive SSRI for mood/behavior Avoid anticholinergics for tremor and antipsychotics fo hallucination Traditional PD meds are not effectivs
72
Drug-induced PD
``` Antipsychotics Antiemetics CCB Valpric acid Lithium Albuterol Caffeine ```

Neuro Quiz 6 (2 decks)

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