Drugs Used for Parkinson’s Disease Chapter 15 Drugs Used for Parkinson’s Disease Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Chapter 15 Lesson 15.1 Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Objectives Prepare a list of signs and symptoms of Parkinson’s disease and accurately define the vocabulary used for the pharmacologic agents prescribed and the disease state Name the neurotransmitter that is found in excess and the neurotransmitter that is deficient in people with parkinsonism Develop a health teaching plan for an individual being treated with levodopa Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Objectives (cont’d) Describe reasonable expectations of medications prescribed for treatment of Parkinson’s disease Identify the period necessary for a therapeutic response to be observable when drugs used to treat parkinsonism are initiated Name the action of carbidopa, levodopa, and apomorphine on neurotransmitters involved in Parkinson’s disease Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Parkinson’s Disease Normally there is balance between neurotransmitters Dopamine – inhibitory effect Acetylcholine – excitatory effect Symptoms caused by the deterioration of dopaminergic neurons with resulting deficiency in dopamine Two types of parkinsonism Primary – idiopathic (unknown cause) Secondary – induced by head trauma, infection, tumors, drug exposure Chronic progressive disorder of the CNS. Named after James Parkinson, the English physician who described the “shaking palsy” in 1817. Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Parkinson’s Disease Key terms Tremors – occur at rest, start in hand, face Dyskinesia – loss of voluntary movement, slow and jerky Propulsive uncontrolled movement – occurs when mobility had deteriorated to cause patient to have quickened and shortened steps; leads to falls Akinesia – loss of movement Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Drug Therapy for Parkinson’s Disease Goal is to minimize symptoms, not cure Restore dopaminergic activity Restore neurotransmitter function Slow deterioration of dopaminergic nerve cells Inhibit excess cholinergic activity (which cause tremors) All symptoms cannot be eliminated because of adverse drug effects Effectiveness of therapy may take several weeks Parkinson’s is individualized and uses a combination of agents because symptoms and disease progression vary greatly among individuals. Therapy begins when symptoms interfere with the ability to function in daily life. Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Management of Parkinson’s Disease Nonpharmacologic Education, nutrition, exercise, support services Pharmacologic Start neuroprotection drugs (selegiline [Eldepryl, Zelapar]) When function impaired, use dopamine agonists Add levodopa (Larodopa) and/or COMT inhibitor Surgery is last resort if symptoms do not improve Stem cell research is ongoing for treatment of Parkinson’s. Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Carbidopa and Levodopa Therapy Carbidopa and levodopa given in combination Actions: Carbidopa reduces the metabolism of levodopa so more of administered levodopa reaches receptor sites Uses: Levodopa is used to replace dopamine deficiency in Parkinson’s Brand names: Sinemet, Parcopa Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Carbidopa and Levodopa Therapy (cont’d) Common adverse effects: Nausea and vomiting, orthostatic hypotension Serious adverse effects: Chewing motions, bobbing, facial grimacing, rocking movements (extrapyramidal symptoms), sudden sleep events, nightmares, depression, confusion, hallucinations, tachycardia, palpitations Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Drug Class: Dopamine Agonist Drug: apomorphine (Apokyn) Actions Stimulate dopamine receptors, temporarily restore motor function Uses Treat hypomobility associated with the wearing off of dopamine agonists near end of dosage cycle Administered subcutaneously Common adverse effects Nausea, vomiting; orthostatic hypotension Chemically related to morphine but has no opioid effect. Serious adverse effects: extrapyramidal symptoms; sudden sleep events, depression, confusion, hallucinations; tachycardia, palpitations, others. Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Chapter 15 Lesson 15.2 Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Objectives Name the action of entacapone and the monoamine oxidase inhibitors, selegiline and rasagiline, as it relates to treatment of Parkinson’s disease List symptoms that can be attributed to the cholinergic activity of pharmacologic agents Cite the specific symptoms that should show improvement when anticholinergic agents are administered to the patient with Parkinson’s disease Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Drug Class: COMT Inhibitor Drugs: entacapone (Comtan, Stalevo) Action Reduce destruction of dopamine in peripheral tissues, allowing more to reach the brain Uses Added to treatment when carbidopa-levodopa become less effective and adverse effects develop Common adverse effects Diarrhea; sedative effects; urine discoloration (brownish orange) Stalevo is a combination drug containing carbidopa, levodopa, and entacapone. Serious adverse effects: neurologic effects (chorea, confusion, hallucinations; orthostatic hypotension). Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Drug Class: Monoamine Oxidase-B Inhibitors Drugs: selegiline (Eldepryl), rasagiline (Azilect) Actions Reduce metabolism of dopamine in the brain, allow greater dopaminergic activity, considered neuroprotective, which slows the destruction of dopamine neurons Uses Added when carbidopa-levodopa loses effectiveness Common adverse effects Constipation, stomach upset Used to improve memory, motor speed, and may increase life expectancy. Serious adverse effects: neurologic effects (chorea, confusion, hallucinations; orthostatic hypotension). Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Drug Class: Anticholinergic Agents Action Reduce hyperstimulation caused by excessive acetylcholine Uses Reduce the severity of the tremor and drooling associated with parkinsonism Common adverse effects Constipation; dryness of mucosa of the mouth, throat and nose; urinary retention; blurred vision For specific drugs, see Table 15-2. Less effective for rigidity, bradykinesia, or postural abnormalities. More useful for patients with minimal symptoms and no cognitive impairment. Serious adverse effects: nightmares, depression, confusion, hallucinations; orthostatic hypotension, palpitations, dysrhythmias. Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Patient Education for Levodopa Discuss expected therapeutic outcomes Explain the many adverse effects – most dose-related and reversible Expect orthostatic hypotension Rise slowly from supine position or sitting position If feeling faint, sit or lie down Monitor blood pressure daily Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.