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26 Cards in this Set
- Front
- Back
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Parkinson Disease Pathophysiology
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Occurs when neurons in a part of the brain (the substantia nigra) die or become impaired
Multifactoral causes These neurons produce dopamine normally; the death of the neurons causes motor symptoms to appear |
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Symptoms of Parkinson Disease
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Non-motor symptoms
- Loss of sense of smell (anosmia) - Constipation - Sleep difficulties - Low mood/Depression; psychosis in advanced ds - Orthostasis Motor Symptoms - Unilateral tremor; spreads bilaterally - Bradykinesia - Stiff facial expression; speech issues - Shuffling walking - Rigidity; cogwheel rigidity -- ratchet-like movement of arms - Postural instability EVEN w/ high doses of most effective meds, the "off" periods will increase |
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TRAP
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Tremor
Rigidity Akinesia/bradykinesia Postural instability |
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Drugs that can cause Parkinsonism
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Phenothiazines (ex. prochlorperazine)
1st gen antipsychotics (ex. haloperidol) 2nd gen antipsychotics (esp. risperidone at higher doses; paliperidone) Metoclopramide (esp. when overdosed) - Disorders are always dose-dependent; higher doses ESP. in elderly patients, are highest risk |
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Treatment
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Initial - levodopa (most effective)
Tremors - anticholinergics (in younger patients only) Can Use MAOI for mild benefit in initial tx As disease progresses, tx will be directed at both reducing "off" periods and limiting dyskinesias |
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Carbidopa/Levodopa Info
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MOA - levo is precursor of dopamine; carbidopa inhibits dopa decarboxylase, preventing peripheral metabolism of levodopa
CONTRA - MAOI w/in 14 days; hx of melanoma or undiagnosed skin lesions SE - *nausea, dizziness, orthostasis; brown, black, or dark urine, saliva or sweat; dyskinesias*, dystonias, dry mouth Possibility of unusual sexual urges, priapism Response fluctuates after long-term use |
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Sinemet, Sinemet CR
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Carbidopa/levodopa --- dopamine replacement agent
Available separately Starting dose 25/100 mg TID SR tab CAN be cut in half; DO NOT crush or chew Parcopa RapiTab - rapidly dissolves on tongue w/o water **70-100 mg of carbidopa is required to inhibit the peripheral conversion and to decrease nausea** |
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Comtan
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Entacapone --- COMT inhibitor
200 mg w/ each dose of carbi/levo MAX 1600 mg/d MOA - used only w/ levodopa to increase levodopa duration of action; inhibits COMT to prevent peripheral and central conversion of levodopa SE - nausea, dyskinesias, dizziness, orthostasis, hypotension, urine discoloration, diarrhea |
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Stalevo
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Levodopa/Carbidopa + entacapone
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Tasmar
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Tolcapone
Not used much d/t hepatotoxicity |
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SInemet Drug Interactions
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CONTRA w/ nonselective MAOIs --- need a 2 wk separation period
DO NOT use w/ dopamine blockers --- will worsen disease symptoms Iron - decreases Sinemet absorption Protein-rich food decrease Sinemet absorption |
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Sinemet Patient Counseling
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DO NOT stop taking suddenly; May take several wks for full effect of med
DO NOT crush or chew Sinemet CR; may be split in half at the score Caution while driving, etc. d/t dizziness May have unusual sexual urges Can darken urine and stain clothing Males - if priapism occurs, stop using med and seek immediate medical attention Call dr if having uncontrollable movements of the mouth, tongue, cheeks, jaw, arms, or legs; or if fever develops Parcopa RapiTab - contains phenylalanine |
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Dopamine agonists
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Act similar to dopamine at the dopamine receptor
SE - dizziness, sudden daytime sleep attacks, N/D/V, orthostasis, peripheral edema, hallucinations, dyskinesias Approved for both PD and restless leg syndrome Pramipexole Ropinirole Rotigotine Apomorphine |
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Apokyn
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Apomorphine --- DA agonist injection for advanced ds
*RESCUE movement agent used for "off" periods 0.2 mL SQ up to 5x/d --- can increase to MAX 0.6 mL CONTRA - 5HT3 antagonists d/t severe hypotension and loss of consciousness SE - *severe N/V, hypotension,* yawning, QT prolongation, somnolence **Start Tigan (trimethobenzamide) 300 mg PO TID or similar antiemetic 3 days prior to initial dose of apomorphine; continue at least during 1st 2 months of tx** |
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Mirapex, Mirapex ER
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Pramipexole
Start 0.125 mg TID, titrate Qwk to 0.5-1.5 mg TID ER --- 0.375 mg QD, titrate Q5-7 days to max dose of 4.5 mg/d Slow dose titration is required d/t orthostasis, dizziness, sleepiness Decrease dose if CrCl < 60 mL/min |
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Requip, Requip XL
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Ropinirole --- dopamine agonist
0.25 mg TID, titrate Qwk to 1-4 mg TID XL --- 2 mg QD, can titrate Q1-2 wks to max dose of 24 mg/d DI - CYP 1A2 substrate; caution w/ 1A2 inhibitors |
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Neupro
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Rotigotine --- DA agonist
PATCH 1, 2, 3, 4, 6, or 8 mg/24 hrs --- apply ONCE daily; same time each day DON'T apply to same site for at least 14 days SE - drowsiness, peripheral edema, HA, fatigue, orthostasis, sleep disturbance, hallucinations, application site rxns, hyperhidrosis DO NOT apply heat source over patch REMOVE in MRI AVOID if allergic to sulfites |
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Ropinirole and Pramipexole Patient Counseling
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Can take w/ or w/o food
Nausea and sleepiness are most common SEs; may fall asleep while doing daily activities Can cause dizziness; caution when rising Avoid meds that can cause drowsiness; DO NOT use alcohol Hallucinations may occur Dose will slowly increase over time |
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Rotigotine Patch Patient Counseling
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Can cause drowsiness
May sweat more than usual; stay hydrated Contains aluminum; patch may burn skin during certain medical procedures; MUST remove prior to MRI Patch can irritate skin; rotate patch site DO NOT expose to heat sources APPLY to stomach, thigh, hip, side of the body, shoulder, or upper arm |
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Apomorphine Patient Counseling
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DO NOT take w/ ondansetron or others of that class
Causes SEVERE N/V --- use Tigan (trimethobenzamide) to reduce nausea DO NOT use alcohol or other medications that make pt sleepy Inject on stomach, upper arm, or upper leg Rotate site w/ every injection SQ injection --- DO NOT inject into a vein |
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Symmetrel
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Amantadine --- blocks DA reuptake into presynaptic neurons, increases DA release from presynaptic fibers
*USED for MILD disease, or for dyskinesias in advanced disease* 100 mg BID-TID; decrease in renal impairment SE - dizziness, toxic delirium, livedo reticularis (cutaneous rxn --- reddish skin mottling, requires drug d/c) |
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Selective MAO-B inhibitors
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Used w/ levodopa or as initial monotherapy
SE similar to levodopa DI - meperidine, tramadol, methadone, propoxyphene, dextromethorphan, St. John's wort, mirtazapine, cyclobenzaprine Tyramine interactions --- low risk, but possible hypertensive crisis KEEP doses at MAO-B selective levels or drugs become non-selective |
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Eldepryl, Zelapar ODT
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Selegiline
5-10 mg QD Zelapar - 1.25-5 mg QD Can be activating; DO NOT dose QHS If BID, take 2nd dose at mid0day ONLY has benefit when used w/ levodopa |
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Azilect
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Rasagiline
0.5-1 mg QD Can be used as initial monotherapy or adjunctive levodopa CONTRA --- use w/ cyclobenzaprine, dextromethorphan, methadone, propoxyphene, St. John's wort, tramadol, meperidine, other MAOI More risky w/ both drugs and tyramine foods |
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Cogentin
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Benztropine --- centrally acting anticholinergic used for tremor in younger patients
0.5-2 mg TID -- start QHS SE - dry mouth, constipation, urinary retention, blurred vision, drowsiness, confusion, tachycardia, high incidence peripheral and central anticholinergic SEs |
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Trihexyphenidyl
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Centrally acting anticholinergic used primarily for tremor in younger patients
1-2 mg TID -- start QHS SE - dry mouth, constipation, urinary retention, blurred vision, drowsiness, confusion, tachycardia, high incidence peripheral and central anticholinergic SEs |
