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63 Cards in this Set
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- Back
- 3rd side (hint)
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Why can't you just treat Parkinson's by giving dopamine?
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Doesn't cross the BBB
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What are the 4 cardinal signs of parkinsonism? How many are required for dx?
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rest tremor
rigidity akinesia gait disturbance typically need 2 or more to call it Parkinson's |
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What sign is virtually pathognomonic for parkinson's?
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Rest Tremor
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What is "the most effective Parkinson's agent"?
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Levodopa
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What is the purpose of giving carbidopa and/or entacapone with levodopa?
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blocks decarboxylation in the peripheral tissues to decrease SEs and permit more levodopa to reach the brain
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Should you start with immediate release or continuous release (CR) cinemet?
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immediate release until stabe --> then switch
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What drug blocks the conversion of levodopa to dopamine in the systemic circulation and the liver?
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Carbidopa
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What drug prevents the O-methylation of Levodopa by inhibiting COMT?
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Entacapone
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Which drug related to entacapone is not used anymore b/c reports of fatal liver injury?
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Tolcapone
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Which symptoms is Levodopa most helpful for? Which symptom is less likely to respond?
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Effective for - akinesia (and maybe tremor/rigidity)
Postural instability is not as likely to respond |
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If you push the dose of levodopa up to almost 1500mg but you're still not getting improvement what is the problem?
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you probably have misdiagnosed the pt
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What needs to be altered when you change from immediate release to sinemet CR?
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Inc. dose up to 30%
(CR tablets are less completely absorbed) |
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Name 3 categories of drugs that tend to interact with levodopa.
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1. antispychotics
2. old nausea meds 3. MAO inhibitors |
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What may occur when antipsychotics are taken with levodopa?
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NMS
(via dopamine receptor blockade) |
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What nausea meds may interfere with levodopa?
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Droperidol
phenothiazine promethazine |
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What are the main peripheral side effects of levodopa that drugs like carbidopa or entacapone were made to decrease?
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N/V, anorexia, orthostatic hypotension
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What are levodopa-induced motor fluctuations?
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occur in 1/2 of pts after taking drug for 5-10yrs
dopamine terminals in the SN degenerate over time which limits normal uptake/release of DA --> decreased buffering of the natural plasma fluctuations occuring during the drugs half life |
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What is the Wearing-Off phenomenon?
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pt begings to be aware of wearing off <4 hours after taking levodopa
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What is the on-off effect?
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later in the course of tx pts develop sudden, unpredictable fluctuations between mobility and immobility
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What is the MOA of selegiline?
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MAO B inhibitor - may also delay dopamine reuptake at the synapse
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When might selegiline be used?
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adjunctive when the efficacy of levodopa is deteriorating
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What can occur when MAO is taken with levodopa? Is this likely to occur in pts taking selegiline?
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hypertensive crisis.
Not as likely with selegiline even when pt ingests tyramine containing foods |
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What are 4 alternative first line treatments for Parkinson's?
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Bromocriptine
Pergolide Pamipexole Ropinirole |
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Name the Ergot Derivatives that may be considered alternate first line tx for Parkinson's.
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Bromocriptime
Pergolide |
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HOw do the Ergot/Non-Ergot Derivatives work?
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they are dopamine receptor agonists - thought to stimulate dopamin activity on the nerves of the striatum and SN
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What are the non-ergot Derivatives?
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Pramipexole
Ropinirole |
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What is ropinirole used to treat besides Parkinson's?
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restless leg syndrome
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Which are more effective the non-ergots or levodopa?
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levodopa
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If pt doesn't respond to levodopa at all will they respond to a non-ergot (or ergot)?
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probably not
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What drugs do pramipexole and ropinirole both interact with?
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Antipsychotics
Metoclopramide, droperidol, prochlorperazine, promethazine |
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What are the cytochrome interactions of ropinirole?
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2D6 inhibitor
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prob w/beta blockers, TCAs, SSRIs
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What are the ADRs of both the ergot derivatives
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can induce retroperitoneal, pleural, and pericardial fibrosis
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bromocriptine and pergolide
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What ADR is unique to pergolide? (not bromocriptine)
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thickening and dysfunction of cardiac valves
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But both can induce retroperitoneal, pleural, and pericardial fibrosis
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What are the main side effects of the non-ergots?
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somnolence!
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Which non-ergot can cause hallucinations and postural hypotension?
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pramipexole
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Which non-ergot can cause syncope and nausea?
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ropinirole
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What (odd) side effect have both non-ergots been linked to?
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compulsive gambling
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In which pt population would you be more likely to start a dopamine agonist rather than levodopa?
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<65
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If PD symptoms are seriously threatening the patient's lifestyle, which drug should be administered?
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levodopa
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What drug is sometimes added to counteract the dyskinesias assosiated with levodopa use?
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amantadine
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How can you treat early morning "off" periods in Parkinson's pts?
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middle-of-the night med dose (either levodopa or dopamine antagonist)
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How can you treat "off" periods during the day?
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reduce med dose intervals or add dopamine agonist
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What type of meal should levodopa not be taken with?
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high protein
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How might you help treat pts who experience the wearing off phenomenon?
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sustained release levodopa may help (in early stages in less advanced disease)
Reducing dose interval by 30-60 min (may help in advanced disease) May consider adding entacapone, dopamine agonist, or selegiline |
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What are some possbile causes of delirium
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infxn (think UTI or pneumonia)
lytes, hypoxia, fecal impaction, meds, malnutrition, catheter, restraints, dehydration, alcohol withdrawl, sleep deprivation, pain |
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What is the first step in management of dementia?
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Determine the type accurately
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Name 4 cholinesterase inhibitors used to treat the symptoms (not disease) of AD.
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Tacrine
Donepezil Rivastigmine Galantamine |
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Why isn't rivastigmine used first line?
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significant N/V/D
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Which cholinesterase inhibitor is most commonly used? (fewest SEs)
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Donepezil
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Why isn't tacrine used much?
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hepatotoxicity
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What are the indications for use of donepezil?
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mild-moderate AD
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What is donepezil used for besides AD?
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vascular dementia
parkinson's dementia lewy body dementia |
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What are the cytochrome interactions of donepezil?
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2D6 and 3A4 substrate
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What class of drugs may diminish the benefit of cholinesterase inhibitors?
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anticholinergics, duh
(diphenhydramine, tolteridine, oxybutynin, TCAs, etc) |
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What cardiac side effect may result from donepezil? Which patient's should you be careful giving it to?
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bradycardia; SSS (tachy-brady) or other SV conduction abdnormalities
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If pt does not have response to cholinesterase inhibitor after 8wks, what should you do?
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Continue the drug (if stopped and restarted the benefit may be lost) . . these drugs can be continued indefinitely
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What drug may actually modify AD, not just treat symptoms?
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memantine
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How does memantine work?
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NMDA antagonist
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What are the clinical indications for use of memantine?
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moderate-severe AD
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Which AD drug has not real drug interactions and the only SE is dizziness?
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memantine
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What agents may be considered for use in AD pts with agitation, aggression, delusions, wandering, etc?
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atypical antipsychotics (olanzapine, quetiapine, or risperidol)
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Ho are depression and sleep disturbances usually treated in AD pts?
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SSRI and newer sleep meds (not TCAs b/c --> confusion)
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What is Capgras syndrome? In which disease may it occur?
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paranoid delusion that family members have been replaced by imposters; AD
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