Parkinson's Disease

• Cogentin
• Anticholinergic

• Artane
• Anticholinergic

• Tremors in younger pts (cognitive impairment in elderly)
• < 70 with tremors and preserved cognitive function
• Use as monotherapy (for tremors) or adjunct to address other cardinal Sx
• - Cogentin (benztropine)
• - Artane (trihexyphenidyl)

• Symmetrel
• Antiviral that increases DA in prefrontal cortex
• Tremors, rigidity, bradykinesia
• Levodopa induced dyskinesia
• Renal dose adjustment
• Good for older patients

• Sinemet
• - carbidopa inhibits carboxylase in periphery (70-100 mg/day)
•   * GI distress, N/V- too much levodopa is getting converted in the periphery, increase carbidopa
• - levodopa crosses BBB, converts to DA, and gets stored
• Titrate up slowly
• Motor complications
• - End of dose wearing off
• - Peak dose dyskinesia
• - Off period dystonia
• - Delayed on
• - Freezing

• End of dose wearing off
• Return of Sx
• Depletion of DA stores (nowhere to store DA- 1 hr ½ life)
• Increase frequency, add COMT inhibitor, MAO-B inhibitor, DA agonist
• - Acute episodes: SQ apomorphine (DA agonist- rescue)
• Occurs mostly at night- use CR/XR

• Absence of drug effect
• Decreased absorption or delayed gastric emptying
• Crush/chew tabs (CR should not be crushed/chewed)
• - ODT on empty stomach
• Rescue- SQ apomorphine

• Inhibition of lower extremities
• Physical Therapy
• Increase dose of carbidopa/levodopa
• Add MAO-B inhibitor or DA agonist

• Involuntary movements of neck, trunk, upper and lower extremities
• Lower dose - Parkinson’s symptoms may return
• Add amantadine or increase dose

• Sustained muscle contractions
• Occurs in lower extremities (feet), in the morning prior to first dose
• At bedtime- DA agonist, XR formulation, baclofen
• Acute/Persistent Dystonia- Focal Botox injection

• Inhibits breakdown of DA
• Monitor for serotonin syndrome
• selegiline (Eldepryl)
• rasagiline (Azilect)

• Eldepryl
• MAO-B inhibitor, higher doses MAO-A
• - Doses > 9 mg watch for serotonin syndrome
• May exacerbate peak dose dyskinesia
• Monotherapy- control of motor Sx
• Adjunct to Sinemet- prolongs DA activity
• Insomnia, hallucinations, jitteriness

• Azilect
• MOA-B inhibitor
• Used early to help with cognitive decline

• Prevents peripheral conversion of L-dopa to DA
• DNU as monotherapy, must be on Sinemet
• Urine discoloration (brown/orange) and late onset diarrhea
• tolcapone (Tasmar)
• entacapone (Comtan)

• Tasmar
• COMT inhibitor
• Not 1st line- hepatotoxicity
• - Monitor ALT/AST (Q2-3 wks x6 months)
• - D/C if ALT/AST is 2x UNL

• Comtan
• COMT inhibitor
• Preferred (1st line)

• —Bromocriptine (Parlodel
• - Ergot derived
• Pramipexole (Mirapex), —Ropinirole (Requip)
• - Non-ergot derived (safer)
• - Used as monotherapy or adjunct (DA agonist reduce motor complications)
• - Preferred in younger patients
• - Common ADRs
•   * N/V, vivid dreaming, sedation, confusion, hypotension, lightheadedness
• apomorphine (Apokyn)

• Parlodel
• Ergot derived- 2nd line
• Vasospasms, cardiac complications

• Mirapex
• Non-ergot derived- 1st line (RLS)
• Preferred in younger patients
• - Reduce motor complications
• Vivid dreams, sedation, confusion, hypotension, light headedness

• Requip
• Non-ergot derived- 1st line (RLS)
• Preferred in younger patients
• - Reduce motor complications
• Vivid dreams, sedation, confusion, hypotension, light headedness

• 1) Investigate alternative causes
• 2) Simplify Parkinson’s disease regimen
• 3) Add clozapine or quetiapine at bedtime

• Apokyn
• Used in acute/emergency situations
• SQ- triggers “on” DA
• N/V- give trimethobenzamide (Tigan) before
• CI (5HT)- dolasetron (Anzemet), granisetron (Sancuso, Granisol), ondasteron (Zofran)
• - Severe hypotension, confusion

Standardized assessment used to document progression of the disease and response to treatment