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Parkinson’s Disease Jawza F. Al-Sabhan PHCL 430.

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Presentation on theme: "Parkinson’s Disease Jawza F. Al-Sabhan PHCL 430."— Presentation transcript:

1 Parkinson’s Disease Jawza F. Al-Sabhan PHCL 430

2 Patient Presentation Chief Complaint HPI
"I have trouble getting myself started, and it takes me longer to do things." HPI Joan Miller is a 58-year-old, right-handed woman who presents to the neurology clinic because of stiffness on her right side over the last 6 months. It takes her longer to do things because it takes more effort to get movement started, and her muscles feel stiff. For the last year, she feels that she does not think as quickly and it takes her longer to remember things. She also complains of constipation and decreased libido for over a year. Recently, it has become difficult to read because the words occasionally look blurry. These symptoms have affected her job performance as a high-school gym teacher, resulting in her contemplating early retirement.

3 Patient Presentation Six months later, Ms. Miller returns to the clinic. Her medications include multivitamin daily, eye emollient ointment (Refresh PM), Metamucil 1 tablespoon twice daily, pramipexole 1 mg 3 times daily Her libido, slowness, stiffness, and thinking have improved. She is better able to perform her job, enjoys the work, and is no longer planning her retirement. Her constipation has improved marginally. She continues to complain of blurred vision but has not been to the ophthalmologist. She now complains of itchy eyebrows and scalp. The patient reports no side effects from the medicine. However, her husband complains that her personality has changed because she shops excessively, often buying duplicates of things, which is straining their budget.

4 Introduction A neurodegenerative disorder caused by progressive death of selected dopaminergic neurons in the CNS. The pathology of this disorder leads to deteriorating motor,autonimic,cognitive and psychiatric function.  First described by James Parkinson in his classic 1817 monograph, "An Essay on the Shaking Palsy,“

5 Epidemiology Affects between 100 and 200 per 100,000 people over 40
Over 1 million people in North America alone Uncommon in people younger than 40 Incidence of the disease increases rapidly over 60 years, with a mean age at diagnosis of 70years

6 Pathophysiology

7 Pathophysiology Dopaminergic cells originating in substantia nigra pars compacta and terminating in the caudate & putamen (nigrostriatal pathway ) are lost gradually during the course of the disease. Pateints initially become symptomatic after 70%-80% cell loss in these area. Accounts for development of rigidity & akinesia May contribute to cognitive symptoms. Factors contributing to autonomic dysfunction Degeneration of the intermediolateral columns of spinal cord Degeneration of the sympathetic and parasympathetic ganglia Loss of brainstem serotonergic & noradrenergic cells contribute to depressive symptoms Formation of Lewy bodies Found in cortex, brainstem and basal forebrain in individuals with preclinical and advance PD Enclosed bodies containing eosinophils and cytosolic proteins Nonspecific finding; may be unrelated to PD process

8 Motor features of Parkinson disease
Cardinal manifestations Craniofacial Musculoskeletal Gait Visual

9 Cardinal manifestations
Tremor Coarse, slow “pill rolling” seen in upper extremities More prominent at rest Usually occurs in one arm at first, then spreads to the contralateral arm. Bradykinesia Generalized slowness of motion Difficulty initiating movement Facial masking Decreas swallowing Rigidity Cogwheeling Muscle stiffness, fatigue and weakness Resistance observed during passive motion a limb. Postural instability Alterations in balance and equilibrium Contributes to falls & injuries

10 Craniofacial Hypomimia (masked facial expression)
Decreased eye blinking Speech disturbances (hypokinetic dysarthria, hypophonia) Dysphagia Sialorrhea

11 Musculoskeletal Micrographia Dystonia Myoclonus
Stooped posture (camptocormia) Kyphosis  Scoliosis Difficulty turning in bed

12 NONMOTOR SYMPTOMS Cognitive dysfunction and dementia
Psychosis and hallucinations Mood disorders including depression, anxiety, and apathy/abulia Sleep disturbances Fatigue Autonomic dysfunction ???? Olfactory dysfunction (Smell sensory) Pain and sensory disturbances Dermatologic findings (seborrhea)

13 STAGES Hoehn and Yahr Scale
Symptoms Stages Unilateral involvement only, minimal or no fx impairment Stage I: Bilateral involvement, without impairment of balance Stage II: Evidance of postural imbalance, some reduction in activities ,capable of leading independent Stage III: Severely disabled, unable to walk and stand unassisted , markedly incapacitated Stage IV: Restricted to bed or wheelchair unless aided Stage V

14 Treatment The pharmacologic treatment of PD can be further divided into Neuroprotective Symptomatic therapy.

15 SYMPTOMATIC THERAPY  The decision to initiate symptomatic medical therapy in patients with PD is determined by the degree to which the patient is functionally impaired. The timing of this decision varies greatly among patients but is influenced by a number of factors, including : The effect of disease on the dominant hand The degree to which the disease interferes with work, activities of daily living, or social and leisure function The presence of significant bradykinesia or gait disturbance Personal philosophy regarding the use of drugs

16 SYMPTOMATIC THERAPY The major drugs available for symptomatic therapy include Levodopa MAO B inhibitors Dopamine agonists COMT inhibitors Anticholinergic agents Amantadine

17 LEVODOPA Levodopa (L-dopa) is well established as the most effective drug for the symptomatic treatment of idiopathic or Lewy body PD. It is particularly effective for the management of akinetic symptoms and should be introduced when these become disabling and are uncontrolled by other antiparkinsonian drugs. Tremor and rigidity can also respond to levodopa therapy, but postural instability is less likely to do.

18 LEVODOPA Mechanism Levodopa is converted to dopamine by dopa decarboxylase for use in striatal neurons. Role in Therapy useful for motor symptom is Stage II-V disease

19 LEVODOPA Formulations
Levodopa is combined with a peripheral decarboxylase inhibitor carbidopa Advantage of combination; Carbipoa to block its conversion to dopamine in the systemic circulation and liver (before it crosses the blood-brain barrier) in order to prevent nausea, vomiting, and orthostatic hypotension. Carbipoa increase F of levodopa to penetrate the CNS. Need app mg\ day of carbidopa to effectively block the peripheral conversion of levodopa. The combination drug carbidopa/levodopa (immediate-release Sinemet) is available in tablets of 10/100, 25/100, and 25/250 mg Controlled release formulation has 70% bioavailability of immediate release 25\100mg, 50\200 mg.

20 Controlled release levodopa preparations are less completely absorbed and require a dose up to 30 percent higher to achieve an equivalent clinical effect. The clinical effect of each tablet is typically less dramatic than for immediate release preparations, since controlled release formulations reach the brain more slowly. This presents a disadvantage in assessing the response of patients just beginning therapy. As a result, it is recommended that therapy be initiated with an immediate release preparation with a subsequent switch to controlled release if desired. Both the immediate and the controlled release formulations appear to maintain a similar level of symptom control after several years of use

21 Dosing  Initial:25/100 mg two to hree times daily with meals avoid high fat meals ???. Interfere with abs. of levodopa in GI tract. Total daily dose of carbidopa/levodopa can be titrated carefully upward over several weeks to a full tablet of 25/100 mg three times daily as tolerated. If pt fail to respond to >1000 mg levodpa reconsider PD diagnosis.

22 Adverse effects  Nausea, somnolence, dizziness, and headache are among the more common side effects that may accompany treatment with levodopa, but they are not likely to be serious in most patients. More serious adverse reactions to levodopa (mainly in older patients) may include confusion, hallucinations, delusions, agitation, and psychosis. Levodopa may also induce a mild to moderate elevation in serum homocysteine levels which in turn may be associated with an increased risk of hip fractures in elderly patients.

23 Adverse effects Motor fluctuations
Occur in at least 50 percent of patients after 5 to 10 years of treatment Called (the wearing-off phenomenon): involuntary movements known as dyskinesia, abnormal postures of the extremities and trunk known as dystonia

24 MAO B INHIBITORS selegiline
Mechanism Selegiline irreversibly and selectively inhibits monoamine oxidase (MAO) type B inhibitor the oxidative metabolism of dopamine Role in Therapy is modestly effective as symptomatic treatment for PD and may have neuroprotective properties (preclinical disease). Adjunctive treatment in Stage I-IV. May use lower doses of levodopa and dopamine agonist.

25 Selegiline Dosing 10 mg per day ; 5 mg qam and 5mg at lunch
Metabolized by liver to …. (to avoid insomnia). However, lower doses are sufficient to induce MAO B inhibition, and 5 mg once a day in the morning is currently recommended. Doses higher than 10 mg daily are of no additional benefit and may result in nonselective MAO inhibition, thereby placing the patient at risk of hypertensive crisis in the absence of dietary restrictions.

26 Selegiline Adverse effects
Nausea and headache amphetamine metabolites of selegiline can cause insomnia Augment levodopa toxicities Potential food- drug interaction (tyramine) Potential drug-drug interaction (SSRI)

Bromocriptine Pergolide Ropinirole Pramipexole D1&D2 receptors Agonist D2 receptor Agonist

28 DOPAMINE AGONISTS Pergolide has been voluntarily withdrawn from the United States market and is best avoided because it is associated with a risk of cardiac valve problems. Injectable apomorphine has been approved by the United States FDA for treatment of motor fluctuations in PD section on Dopamine agonists. Advantage Unlike levodopa-carbidopa ,these drugs are direct agonists that do not require metabolic conversion do not compete with amino acids for transport across the gut or into the brain do not depend upon neuronal uptake and release. longer duration of action .

29 DOPAMINE AGONISTS Role of Therapy
Monotherapy in early disease (younger pt) to delay the time to start levodopa. Less effective monotherapy for sever stages >stage 3

30 DOPAMINE AGONISTS Role of Therapy
Monotherapy — Dopamine agonists (DAs) were initially introduced as adjunctive treatment for advanced PD complicated by reduced levodopa response, motor fluctuations, dyskinesia, and other adverse effects of levodopa. However, the hypothetical concern that free radicals generated by the oxidative metabolism of dopamine contribute further to the degeneration of dopaminergic neurons has prompted some investigators, despite lack of conclusive evidence, to advocate the early use of DAs as an levodopa-sparing strategy. With this approach, treatment with levodopa can be postponed and saved for a later time in the course of the disease, when disability worsens and the less effective agonists no longer provide adequate benefit. This strategy is based upon the unproven concept that the long-term duration of a given patient's responsiveness to levodopa is finite and that the drug, like money in a savings or retirement account, should be rationed. However, whether reduced responsiveness to levodopa over time is due to a decline in drug response or progression of underlying PD is currently uncertain.

Bromocriptine is usually started at 1.25 mg twice a day; the dose is increased at two to four week intervals by 2.5 mg a day. Most patients can be managed on 20 to 40 mg daily in three to four divided doses, although total daily doses as high as 90 mg can be used. Pramipexole is usually started at mg three times a day. The dose should be increased gradually by mg per dose every five to seven days. Most patients can be managed on total daily doses of 1.5 to 4.5 mg. Ropinirole Is usually started at 0.25 mg three times a day. The dose should be increased gradually by 0.25 mg per dose each week for four weeks to a total daily dose of 3 mg. After week four, the ropinirole dose may be increased weekly by 1.5 mg a day up to a maximum total daily dose of 24 mg. Benefit most commonly occurs in the dosage range of 12 to 16 mg per day.

32 DOPAMINE AGONISTS Adveres effect
Poorly tolerated by about 30% due to Allergy Palpitation Sinus tachycardia Agitation Edema (hands, feet, face) Plural effusion

33 COMT INHIBITORS Mechanism Drugs
Inhibits the enzyme catechol-O-methyl transeferase that converts levodopa to 3-O-methyldopa and converts dopamine to 3-methooxytyramine Drugs Tolcapone 100mg,200mg Entacapone 200mg Carbidopoa/levodopa/entacapone

34 COMT INHIBITORS Role in therapy:
They are ineffective when given alone, but they may prolong and potentiate the levodopa effect when given with a dose of levodopa. These medications are mainly used to treat patients with motor fluctuations who are experiencing end-of-dose wearing "off" periods.

  The starting dose of tolcapone is 100 mg three times daily; the clinical effect is evident immediately, up to 600 mg/day The dose of entacapone is one 200 mg tablet with each dose of levodopa, up to a maximum of eight doses per day. ???mg/day

36 COMT INHIBITORS Adverse effects
Tolcapone  The most common side effects of tolcapone are due to increased dopaminergic stimulation and include dyskinesia, hallucinations, confusion, nausea, and orthostatic hypotension. The adverse effects are managed by lowering the dose of levodopa either before or after the addition of tolcapone. Diarrhea that is poorly responsive to antidiarrheal medications appears in approximately 5 percent of patients. An orange discoloration of the urine is a common but benign adverse event. Elevations in liver enzymes may rarely occur. Monitoring??? Entacapone are similar to tolcapone ADR, although entacapone has thus far not been associated with hepatotoxicity

37 ANTICHOLINERGICS Mechanism Role of therapy Drugs
Antagoniza muscarinic cholinergic receptors in the striatum Role of therapy Used to control tremor Drugs Trihexyphenidyl Benztropine

 Trihexyphenidyl The starting dose of trihexyphenidyl is 0.5 to 1 mg twice daily, with a gradual increase to 2 mg three times daily. Benztropine traditionally is more commonly used by psychiatrists for the management of antipsychotic drug-induced parkinsonism; the usual dose is 0.5 to 2 mg twice daily. .

39 ANTICHOLINERGIC Adverse effects
Peripheral antimuscarinic side effects include dry mouth, blurred vision, constipation, nausea, urinary retention, impaired sweating, and tachycardia. Caution is advised in patients with known prostatic hypertrophy or closed-angle glaucoma. Discontinuation of anticholinergic drugs should be performed gradually to avoid withdrawal symptoms that may manifest as an acute exacerbation of parkinsonism, even in those in whom the clinical response has not seemed significant.

40 AMANTADINE Mechanism Role of therapy
Blocks presynapatic dopamine reuptake; causes release of dopamine from storage sites Synergistic effects with levodopa and dopamine agonists Role of therapy Improves bradykinaseia, tremor, and rigidity, in pateints with Stages I-IV disease

41 AMANTADINE Dosing   The dose of amantadine in early PD is 200 to 300 mg daily; there is no evidence that larger doses are of additional benefit. The main advantage of this agent is a low incidence of side effects. It is excreted unchanged in the urine and should be used with caution in the presence of renal failure. Adverse effects — Peripheral side effects include ankle edema, which are rarely severe enough to limit treatment. Confusion, hallucinations, and nightmares occur infrequently, but unpredictably, even after long periods of use without side effects. These effects are more likely when amantadine is used together with other antiparkinsonian drugs in older patients.

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