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Pharmacological Management of Parkinsons Disease Dr EGS Spokes Consultant Neurologist Leeds General Infirmary.

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Presentation on theme: "Pharmacological Management of Parkinsons Disease Dr EGS Spokes Consultant Neurologist Leeds General Infirmary."— Presentation transcript:

1 Pharmacological Management of Parkinsons Disease Dr EGS Spokes Consultant Neurologist Leeds General Infirmary

2 Background Very challenging - bespoke - not off the peg Side effects pose major problems Before 1970 - anticholinergics/amantadine/stereotactic surgery Since 1970 - L-dopa L-dopa + peripheral DDCI Selegiline ( MAOB-I ) Bromocriptine Other Dopamine Agonists Apomorphine Entacapone ( COMT-I ) Before 1970 - life expectancy c. 12 years - now improved

3 Levodopa L-dopaDopamineReuptake MAOB COMT DDC Best treatment - No response ? PD Complications c. 10% p.a. Related to duration/dosage Dose related motor fluctuations - wearing off ± dystonia - peak dose dyskinesia Random fluctuations Psychiatric disorder ? L-dopa accelerates cell death

4 Management of L-dopa Treatment Failures On/Off Chart

5 Management of L-dopa Treatment Failures Dose related Wearing off ± dystonia fractionate dose / dispersible prolong effect with selegiline / entacopone add dopamine agonist Peak dose dyskinesia fractionate dose / reduce if possible amantadine Random as above + ? protein restriction apomorphine - penject / infusion

6 Dopamine Agonist Monotherapy Ergot derivatives - Bromocriptine / Pergolide / Cabergoline Non-ergots - Ropinirole / Pramipexole All associated with a lower incidence of motor fluctuations + dyskinesia c.5% Advantage less clear in >70s Use if life expectancy 5 years ? Neuroprotective - Ropinirole PET study / Pramipexole SPECT study

7 Psychiatric Complications Hallucinations - Delusions - Hypersexuality - Confusion Reduce / withdraw drugs in order : Anticholinergics Amantadine Selegiline ( ? try Zelapar if worse ) Entacapone Agonist L-dopa ? atypical neuroleptic - olanzapine / quetiapine / clozapine ? anticholinesterase

8 Non – Motor Problems Myalgia Depression Somnolence Dementia Autonomic - anticholinergic - TCA / SSRI - ? nocturnal sleep disturbed - fractionate doses - ? modafanil - anticholinesterase - postural hypotension - constipation - bladder disturbance - sweating / flushing


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