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63 Cards in this Set

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Why can't you just treat Parkinson's by giving dopamine?
Doesn't cross the BBB
What are the 4 cardinal signs of parkinsonism? How many are required for dx?
rest tremor
gait disturbance

typically need 2 or more to call it Parkinson's
What sign is virtually pathognomonic for parkinson's?
Rest Tremor
What is "the most effective Parkinson's agent"?
What is the purpose of giving carbidopa and/or entacapone with levodopa?
blocks decarboxylation in the peripheral tissues to decrease SEs and permit more levodopa to reach the brain
Should you start with immediate release or continuous release (CR) cinemet?
immediate release until stabe --> then switch
What drug blocks the conversion of levodopa to dopamine in the systemic circulation and the liver?
What drug prevents the O-methylation of Levodopa by inhibiting COMT?
Which drug related to entacapone is not used anymore b/c reports of fatal liver injury?
Which symptoms is Levodopa most helpful for? Which symptom is less likely to respond?
Effective for - akinesia (and maybe tremor/rigidity)

Postural instability is not as likely to respond
If you push the dose of levodopa up to almost 1500mg but you're still not getting improvement what is the problem?
you probably have misdiagnosed the pt
What needs to be altered when you change from immediate release to sinemet CR?
Inc. dose up to 30%
(CR tablets are less completely absorbed)
Name 3 categories of drugs that tend to interact with levodopa.
1. antispychotics
2. old nausea meds
3. MAO inhibitors
What may occur when antipsychotics are taken with levodopa?
(via dopamine receptor blockade)
What nausea meds may interfere with levodopa?
What are the main peripheral side effects of levodopa that drugs like carbidopa or entacapone were made to decrease?
N/V, anorexia, orthostatic hypotension
What are levodopa-induced motor fluctuations?
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
What is the Wearing-Off phenomenon?
pt begings to be aware of wearing off <4 hours after taking levodopa
What is the on-off effect?
later in the course of tx pts develop sudden, unpredictable fluctuations between mobility and immobility
What is the MOA of selegiline?
MAO B inhibitor - may also delay dopamine reuptake at the synapse
When might selegiline be used?
adjunctive when the efficacy of levodopa is deteriorating
What can occur when MAO is taken with levodopa? Is this likely to occur in pts taking selegiline?
hypertensive crisis.
Not as likely with selegiline even when pt ingests tyramine containing foods
What are 4 alternative first line treatments for Parkinson's?
Name the Ergot Derivatives that may be considered alternate first line tx for Parkinson's.
HOw do the Ergot/Non-Ergot Derivatives work?
they are dopamine receptor agonists - thought to stimulate dopamin activity on the nerves of the striatum and SN
What are the non-ergot Derivatives?
What is ropinirole used to treat besides Parkinson's?
restless leg syndrome
Which are more effective the non-ergots or levodopa?
If pt doesn't respond to levodopa at all will they respond to a non-ergot (or ergot)?
probably not
What drugs do pramipexole and ropinirole both interact with?
Metoclopramide, droperidol, prochlorperazine, promethazine
What are the cytochrome interactions of ropinirole?
2D6 inhibitor
prob w/beta blockers, TCAs, SSRIs
What are the ADRs of both the ergot derivatives
can induce retroperitoneal, pleural, and pericardial fibrosis
bromocriptine and pergolide
What ADR is unique to pergolide? (not bromocriptine)
thickening and dysfunction of cardiac valves
But both can induce retroperitoneal, pleural, and pericardial fibrosis
What are the main side effects of the non-ergots?
Which non-ergot can cause hallucinations and postural hypotension?
Which non-ergot can cause syncope and nausea?
What (odd) side effect have both non-ergots been linked to?
compulsive gambling
In which pt population would you be more likely to start a dopamine agonist rather than levodopa?
If PD symptoms are seriously threatening the patient's lifestyle, which drug should be administered?
What drug is sometimes added to counteract the dyskinesias assosiated with levodopa use?
How can you treat early morning "off" periods in Parkinson's pts?
middle-of-the night med dose (either levodopa or dopamine antagonist)
How can you treat "off" periods during the day?
reduce med dose intervals or add dopamine agonist
What type of meal should levodopa not be taken with?
high protein
How might you help treat pts who experience the wearing off phenomenon?
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
What are some possbile causes of delirium
infxn (think UTI or pneumonia)

lytes, hypoxia, fecal impaction, meds, malnutrition, catheter, restraints, dehydration, alcohol withdrawl, sleep deprivation, pain
What is the first step in management of dementia?
Determine the type accurately
Name 4 cholinesterase inhibitors used to treat the symptoms (not disease) of AD.
Why isn't rivastigmine used first line?
significant N/V/D
Which cholinesterase inhibitor is most commonly used? (fewest SEs)
Why isn't tacrine used much?
What are the indications for use of donepezil?
mild-moderate AD
What is donepezil used for besides AD?
vascular dementia
parkinson's dementia
lewy body dementia
What are the cytochrome interactions of donepezil?
2D6 and 3A4 substrate
What class of drugs may diminish the benefit of cholinesterase inhibitors?
anticholinergics, duh

(diphenhydramine, tolteridine, oxybutynin, TCAs, etc)
What cardiac side effect may result from donepezil? Which patient's should you be careful giving it to?
bradycardia; SSS (tachy-brady) or other SV conduction abdnormalities
If pt does not have response to cholinesterase inhibitor after 8wks, what should you do?
Continue the drug (if stopped and restarted the benefit may be lost) . . these drugs can be continued indefinitely
What drug may actually modify AD, not just treat symptoms?
How does memantine work?
NMDA antagonist
What are the clinical indications for use of memantine?
moderate-severe AD
Which AD drug has not real drug interactions and the only SE is dizziness?
What agents may be considered for use in AD pts with agitation, aggression, delusions, wandering, etc?
atypical antipsychotics (olanzapine, quetiapine, or risperidol)
Ho are depression and sleep disturbances usually treated in AD pts?
SSRI and newer sleep meds (not TCAs b/c --> confusion)
What is Capgras syndrome? In which disease may it occur?
paranoid delusion that family members have been replaced by imposters; AD