Therapeutics - PD

Card Set Information

Therapeutics - PD
2015-03-23 15:53:17
Therapeutics PD
Therapeutics - PD
Therapeutics - PD
Show Answers:

  1. Drug induced Parkinson’s agents:
    • Phenothiazine antiemetics
    • Metoclopramide – Biggest culprit
    • Neuroleptics
    • SSRI’s, amiodarone, valproic acid, lithium are rarely implicated
  2. Diagnosis:
    • 2 hallmark symptoms present at time of diagnosis
    • Resting tremor
    • Bradykinesia
    • Rigidity
    • Postural reflex impairment - Rare
    • Alleviation of symptoms with dopamine replacement
  3. Carbidopa/Levodopa brand name:
    • Immediate release: tablets (Sinemet®), Orally disintegrating (Parcopa®)
    • Initiate Carbidopa/Levodopa at:
    • 25/100
  4. Adjust Carbidopa/Levodopa by what interval and to what dose
    QOD to 500-6000 Levodopa
  5. ER/CR/Continuous R Carbidopa/Levodopa brand names and specific factors:
    • Sinemet CR: Can split but no crushing, higher initial dose = not absorbed as well as IR
    • Rytary: IR/ER beads in Cap, can sprinkle on Applesauce, 1 hour benefit over Sinemet
    • Duopa: J pump into gut, severe disease w/ motor fluctuation, daytime only
  6. Carbidopa/Levodopa consideration:
    • Give on empty stomach
    • Taper to avoid NMS
    • No drug Holidays!
    • Carbidopa: Minimum daily dose is 75-100mg, Enzyme is saturated at approximately 125mg
    • Short T1/2, but long DOA b/c brain stores Levodopa in DA neurons, DOA shortens as disease progresses b/c DA neuron storage declines
    • Subject to wearing off and on-off phenomena (off = decreased mobility)
  7. SE of Carbidpoa/Levodopa
    Nausea, Dizziness, Insomnia ,Hallucinations, Confusion, Hypotension
  8. How is wearing off treated:
    Wearing off = due to less storage room for DA, Add another drug or shorten interval
  9. What are the DA agonists:
    Bromocriptine (Parlodel®), Pramipexole (Mirapex®, Mirapex ER®), Ropinirole (Requip®, Requip XL®), Apomorphine (Apokyn®
  10. Brand name Bromocriptine (
  11. Brand name Pramipexole
    (Mirapex®, Mirapex ER®)
  12. Brand name Ropinirole
    (Requip®, Requip XL®)
  13. Brand name Apomorphine
  14. What are the considerations for DA agonists?
    • Mono or Polytherapy – Levodopa sparing
    • Longer T1/2s
    • Reduce pulsitile receptor stimulation
    • ER are 1x day
    • Dyskinesias less common, particularly when added to levodopa
    • Decrease levodopa dose upon DA initiation
    • More expensive
    • Watch for excess sleepiness
    • Tapering necessary (NMS)
    • Transdermal formulation: Adherence, reduced absorption variability, don’t have to swallow, Smoother motor fluctuations, prevents night symptoms
  15. SE for DA agonist:
    SE: Hallucinations, Fatigue/somnolence, narcoleptic like attacks, Edema (below knee), Nausea, Hypotension, Pleuropulmonary fibrosis (ergots), Impulsivity
  16. Brand name for Amantadine: (influenza A treatment)
    • Symmetrel®
    • Amantadine (Symmetrel ) is used for:
    • For Tremor
    • Low efficacy and wanes quickly
  17. Amantadine (Symmetrel ) SE
    Anticholinergic (mild), Nightmares, Insomnia, Confusion, Levido reticularis, rapid Withdrawal encephalopathy and NMS
  18. Amantadine (Symmetrel ) considerations:
    • Adjust for renal impairment
    • QD or BID
  19. Anticholinergics
    Benztropine (Cogentin®), Trihexyphenidyl (Artane®), Diphenhydramine (Benadryl®)
  20. Brand name Benztropine
  21. Brand name Trihexyphenidyl (
  22. Brand name Diphenhydramine (
  23. What are the considerations for Anticholinergics:
    • Offset cholinergic sensitivity caused by dopamine depletion
    • Avoid in: Elderly, BPH, narrow-angle glaucoma, constipation
    • TID-QID
  24. What are the MAO-B inhibitors
    • Selegiline (approved as adjunct)
    • IR (Eldepryl®)
    • ODTs (Zelapar®) = fast OOA and no 1st pass
    • Rasagiline (Azilect®) (approved as monotherapy, fewer hallucinations)
  25. What are the considerations for MAO-B inhibitors:
    • Mono or adjunct
    • Decrease Levodopa dose by 50% if used as an adjunct to avoid dyskinesias
    • Prevents MAO metabolism of DA
    • Dose in AM, if BID take second dose by 1pm = causes insomnia
    • Low risk of serotonin syndrome (rapid development), NMS (3 days to develop) and Tyramine interactions w/ food at normal dose
  26. What are the COMT inhibitors –
    • Tolcapone (Tasmar)– Crosses BBB, dose anytime
    • Hepatotoxic
    • Entacapone (Comtan) combo– Peripheral only, dose same time as Sinemet
    • Poor response = give dose 30 min after Sinemet
    • Entacapone w/ Levo/carba (Stalevo)
    • Increased Dyskinesia risks, increased prostate cancer, potential MI risk
    • Not first line
  27. What are the considerations for COMT inhibitors?
    • Inhibit the breakdown of dopamine or levodopa by catechol-o-methyltransferase
    • May be increased COMT actiivyt due to compensation from carbidopa inhibition of decarboxylase
    • Increases On time, T1/2 and AUC of Levodopa
    • ONLY AN ADJUNCT TO SINEMET – May need to reduce dose by 25% at first use
    • Increased Dyskinesias b/c DA is increased
    • SE: discolored urine or sweat, diarrhea (may need d/C)
    • How is Depression in PD treated?
    • Pramipexole (Mirapex) = can be useful for depression and disease
    • D3 receptor agonist = affects mood
    • SSRIs, SNRIs, and TCAs – TCAs have most evidence but hard to tolerate in elderly
  28. How is Psychosis in PD treated?
    • Remove in order: Anticholinergics, Amantadine/MAO inhibitors, Dopamine agonists, COMT inhibitors, Levodopa
    • Quetiapine - No fluctuation in motor control
    • Not the best efficacy
    • Clozapine - Best data, No fluctuation in motor control
    • Toxicities limit use
  29. What are the considerations for treating Psychosis in PD?
    • linked to nursing home placement
    • Do not use traditional Anti-psychotics
    • Rule out infection or metabolic cause
  30. What is used to treat Dementia in PD?
    • Rivastigmine (Exelon®)
    • Causes motor deterioration
  31. Rivastigmine brand name:
  32. Sleep disorder treatments:
    • Frequent or early morning wakening – daytime activities to treat
    • Restless leg syndrome: Ropinirole, pramipexole, levodopa all used to treat
    • Excessive daytime sedation: Modafanil (Provigil®)
    • REM behavior disorder: Nighttime aggression: Clonazepam (Klonopin ®)
  33. Modafanil brand name:
  34. Clonazepam brand name:
    (Klonopin ®)
  35. How areGI issues treated in PD?
    • Constipation: Polyethylene glycol (Miralax), with stimulant as a back-up
    • Nausea: Concurrent with Carbidopa dose
    • CAUTION: metoclopramide or prochlorperazine B/ C of DA effects
  36. How should Falls be treated in PD?
    Calcium/vitamin D and usually a bisphosphantate
  37. Hypotension: 20/10 reduction common, how do you treat?
    • Only treat is symptomatic
    • Lewey bodies effect baroreflex
    • Postprandial cause:
    • Eat smaller meals more often, Avoid high carb and fat
    • Tx:
    • Increase sodium, caffeine and fluid
    • Mild exercise (walk if safe)
    • Elevated head of bed
    • Avoid alcohol, warm, humid weather
    • Change positions slowly
    • Midodrine (ProAmatine®) – take >4 hrs prior to bedtime
    • Fludrocortisone (Florinef®) – not good for supine HPO b/c long DOA
    • Droxidopa (Northera®) – requires dopadecarboxylase for activation – NMS
  38. Midodrine brand name
    (ProAmatine®) – take >4 hrs prior to bedtime
  39. Fludrocortisone brand name
    (Florinef®) – not good for supine HPO b/c long DOA
  40. Droxidopa brand name
  41. Sexual Dysfunction Tx:
    • PDE-5I safe
    • Levodopa may increase libido
    • Melanoma – increased risk, screen regularly