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Parkinson's Disease

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by

Ming Cai

on 6 January 2017

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Transcript of Parkinson's Disease

Parkinson's Disease
QUESTION 2:
Discuss the major drug classes used in the management of Parkinson’s disease? What system do they affect? How can these medications be combined to avoid adverse effects associated with mono therapy?

Starting Parkinsons therapy?
68 years
Bradykinesia
Cogwheel rigidity
“Pill-rolling” tremor on right
Festinant gait
BP 102/64
HR 48/min

Delaying treatment
Question 1:
Based on clinical presentation and medication review, can you see where this patient’s medication regimen could be changed? Why?

1.
Metaclopramide 10mg prn
should be decreased or discontinued because it blocks dopamine receptors (peripheral and central) and can worsen or induce Parkinson-like symptoms
2.
Bisoprolol 5mg OD
should be reduced or discontinued due to bradycardia
3.
Perindopril 5mg OD
should be reduced or discontinued due to low BP
4. aspirin
Drugs to treat Parksinson's disease
Key question
Are symptoms affecting quality of life or work performance?


Starting treatment early
Benefits Vs Risks
Benefits

Improvement of symptoms
Prolongation of independence

Risks
Side effects of treatment
Motor fluctuations at an earlier age
Tolerance to dopamine agonists

Benefits
Prolonging treatment effectiveness
Unsteadiness
Falls
Fractures
Depression
Anxiety
Job performance
Risks
In younger patients (<65yrs) it’s reasonable to start with
a dopamine agonist

Motor complications occur in 50% of patients after 5-10 years of treatment

Dopamine agonists risk impulse control disorders

Dopamine Agonist Vs Levodopa
5-10+ medications

More drugs + decreased clearance = toxicity and interactions

“Prescribing cascade” – adverse drug event is
interpreted as a new medical condition and results in the addition of another drug

Independent risk factor for hip fracture

Regular medication reviews

Polypharmacy in the elderly
25-50% reduction in dose of drugs
excreted both renally and hepatically

Caution with certain drugs renal failure
Vancomycin
Gentamicin
Rivaroxaban
Dabigatran
Metformin
Bisphosphonates
Nitrofurantoin

Decreased Clearance
High risk drugs
for interactions
Warfarin
Clarithromycin
Erythromycin
Metronidazole
Aspirin
NSAID

In combination with BDZs or drowsy
antihistamines can cause
falls and fractures

Neuroleptics
In combination with diuretics,
the hypokalmeia can cause
digoxin toxicity

Digoxin
STOPP/START criteria
1. PPIs for uncomplicated peptic ulcer after >8 weeks treatment
2. Aspirin with no indication
3. >1 fall
Benzodiazepines
Neuroleptic drugs
Long-term opiates

4. Loop diuretics as monotherapy for hypertension
5. Long-term NSAIDs for osteoarthritis

STOP
Warfarin/aspirin/noac in chronic AF
Statin therapy
ACEi in chronic heart failure
SABA/SAMA in COPD
Anti-depressants
Calcium and vitamin D in osteoporosis
Metformin in T2DM with no renal impairment
START

apomorphine: potent; con't subcut. infusion to even out end of dose effects
bromocriptine (ergot)
pramipexole, ropinirole, (non ergot)
Non ergot preferred because they don’t cause vasoconstriction
Dopamine agonists
amantadine

Levodopa
/carbidopa** together
L-dopa can cross the BBB, converted by dopa decarboxylase in the CNS to dopamine.
ADR
: arrhythmia from increased catecholamine formation. Dyskinesia, the on-off phenomenon, or akinesia between doses, visual hallucinations, psychosis
Increase dopamine release
Selegiline, rasagiline: a selective MAO-inhibitor. May enhance effects of L-dopa
useful in the early stages of PD
Entacapone, tolcapone: COMT inhibitors, prevent L-dopa breakdown & may lessen the "off" time
Prevent dopamine breakdown
benzhexol, orphenadrine
can cause confusion in the elderly
benztropine
helps improve tremor and rigidity but little effect on bradykinesia
Antimuscarinics
**Carbidopa is a peripheral decarboxylase inhibitor, and prevents L-dopa from being converted peripherally and prevent the side effects that occur when dopamine is peripheral
Full transcript