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BCPS study guide

Parkinson's and Multiple Sclerosis

QuestionAnswer
cardinal signs of PD akinesia/hypokinesia, rigidity, tremor, posture/gait abnormalities
secondary signs of PD cognitive dysfunction, autonomic dysfunction, speech disturbances, micrographia, masked facies
can start pt on a dopamine agonist or levodopa. what are the primary symptom management advantages of each drug? levodopa improves motor disability and dopamine agonists lessen motor complications.
MAOb inhibitors available for PD selegiline and rasagiline
what problems arise with doses of selegiline greater than 10 mg daily decrease MAOb selectivity
ADEs with selegiline hallucinations, nausea, orthostatic hypotension, insomnia
what is the mechanism for insomnia with selegiline it is metabolized to amphetamine
what drugs should be contraindicated with MAObs and why tramadol, methadone, dextromethorphan, sympathomimetics, fluoxetine/fluvoxamine, meperidine due to serotonin syndrome risk. also cipro can double the concentration via cyp inhibition
purpose of carbidopa in PD prevents peripheral levodopa conversion to dopamine allowing greater concentrations into the CNS.
dietary concerns with carbidopa/levodopa high protein diets decrease absorption
acute adverse effects of Sinemet GI, hypotension, cardiac arrhythmias, confusion, agitation, hallucinations
long term adverse effects of Sinemet wearing off and on off, dyskinesias (involuntary movements)
return of PD symptoms before the next dose of Sinemet. How do you treat this? wearing off. treat with amantadine.
profound unpredictable return of PD sx without respect to dosing interval. How do you treat this? on-off. treat with entacapone, an MAOb inhibitors, pamipexole, ropinirole, apomorphine
typical ratio of carbidopa/levodopa 25/100 mg
direct dopamine agonist options for treatment of PD bromocriptine, pramipexole, ropinirole, rotigotine
ADEs associated with direct dopamine agonists GI sx. postural hypotension, hallucinations, hypersexuality, compulsive behaviors.
contraindications with apomorphine 5HT3 antagonists (ondansetron, palonosetron etc) and sulfite allergy
dosing concerns with apomorphine poor PO bioavailability due to extensive first pass metabolism. given as a SQ shot.
ADEs associated with apomorphine severe NV requires trt with trimethobenzamide before treatment and for at least 6 weeks during treatment. hypotension, hallucinations, dyskinesias
what is the role of anticholinergics in the treatment of PD and what drugs are used tremor. trihexyphenidyl and benztropine
role of amantadine in treatment of PD. and ADEs antidyskinesia agent. dizziness, insomnia, anxiety, livedo reticularis, nausea, nightmares
COMT inhibitor drugs used for PD and ADEs and role in therapy used to decrease dopamine breakdown to increase levodopa in periphery. tolcapone. tolcapone req consent form due to hepatotoxicity. entacapone ADEs: dyskinesias, N/D-delayed up to 2 weeks, urine discoloration to orange, hallucinations and vivid dreams
preferred antipsychotics used in PD related to drug reactions or from disease clozapine or quetiapine
how to treat dyskinesias associated with PD lower levodopa dose or add amantadine
type of MS in which episodes of acute worsening of neurologic function are followed by a varying degree of recovery with a stable course between attacks. relapsing remitting MS. common at diagnosis
type of MS in which initial relapsing remitting disease course is followed by progression with or without occasional relapses, minor remissions and plateaus secondary progressive. presents in about half of patients after ~10 years.
type of MS in which gradual almost continuous worsening occurs with minor fluctuations but no distinct relapses. primary progressive - ~10% of patients at diagnosis
type of MS in which disease is progressive from onset with clear acute relapses with or without recovery with periods between relapses characterized by continuing progression. progressive-relapsing.of patients at diagnosis
how are acute relapses treated in MS corticosteroids. methylpred IV 1 g QD x 3-5 days or PO prednisone 1250 mg QOD. IV ACTH
disease modifying drugs for MS beta interferons (i.e. avonex, betaseron, extavia, rebif), dimethyl fumarate (Tecfidera), glatiramer acetate (Copaxone), fingolimod (Gilenya), Mitoxantrone (Novantrone), natalizumab (Tysabri), teriflunomide (Aubagio),
ADEs associated with beta interferons injection site reactions, flu like symptoms (usually limited to first couple months), neutralizing antibodies (18-24 months of therapy and may increase relapse rates with pts with high antibody titers but may disappear with continued therapy)
ADEs associated with dimethyl fumarate (Tecfidera) flushing helped with ASA and taking with food, starts 30 min after dose and ends after 30 mins. GI effects peak within first month. lymphocytes decrease by 30% in first year then stabilize
ADEs associated with glatiramer acetate (Copaxone) injection site reactions, flusing, chest tightness, palpitations, anxiety, shortness of breath
ADEs associated with fingolimod (Gilenya) bradycardia requiring monitoring for 6 hours after first dose and after any break over 2 wks in duration. AV conduction delays - first and second degree block, decrease in lymphocytes poss inc in infections. macular edema, resp effects, HTN, inc LFTs
ADEs associated with mitoxantrone (Novantrone) potential for toxicity so only used for pts with rapidly advancing disease resistant to other therapies. cardiotoxicity requiring monitoring with ECG and not related to dose. acute leukemia in 0.8% of pts,
ADEs associated with Natalizumab (Tysabri) hypersensitivity reactions, progressive multifocal leukoencephalopathy. reserved for failed therapies.
ADEs for teriflunomide (Aubagio) liver tox, GI effects, alopecia, rash, infection including neutropenia and lymphopenia, preggers categpory X
due to the extremely long half live of terifunomide (Aubagio), what treatments can help to accelerate elimination activated charcoal and cholestyramine
treatment for fatigue associated with MS rest, assistive devices, cooling strategies, exercise, stress management, amantadine, methylphenidate
treatment for spasticity associated with MS must be centrally acting. first line baclofen or tizanidine. second line dantrolene, diazepam. third line intrathecal baclofen. focal spasticity botox
treatment of walking impairment associated with MS
Created by: mjuhlin