Presentation on theme: "Initial Diagnosis and Management of Parkinson’s Disease"— Presentation transcript:
1 Initial Diagnosis and Management of Parkinson’s Disease Jay K. Johnson, D.O.
2 ObjectivesBe familiar with how to make the diagnosis of Parkinson’s diseaseBe aware of some of the differential diagnostic considerations of patient who present with ParkinsonismUnderstand the current medical and surgical options for Parkinson’s disease
3 Parkinson’s Disease Diagnosis Rest tremor – Often unilateralRigidityAkinesia or bradykinesiaPostural instabilityThe usual criteria for a clinical diagnosis of Parkinson’s disease requires at least 2 of these 4 features.
5 Parkinson’s Disease Diagnosis Features most suggestive of Parkinson’s disease include asymmetric or unilateral onsetTremor at restGood response to levodopa
6 Parkinson’s Disease Suspect an Alternative Diagnosis Rapidly progressive courseLack of dopaminergic responseEarly postural instabilityCerebellar signsEarly autonomic featuresPyramidal signsRapidly progressing or early dementiaSupranuclear gaze palsy, slowed saccades
7 Parkinson’s Disease Suspect an Alternative Diagnosis Early fallsSymmetry of motor manifestationsLack of tremor
8 Treatment of Parkinson’s Disease NeuroprotectiveSurgicalSymptomaticNon-pharmacologic
9 Treatment of Parkinson’s Disease Neuroprotective At present there are no proven neruoprotective therapiesMinocycline, creatine, caffeine, coenzyme Q 10, estrogen, pramipexole, ropinirole, rasagiline, GPI 1485, GM-1 ganglioside are currently in clinical trials (NINDS)
10 Treatment of Parkinson’s Disease Surgical It will often reduce “off” time and dyskinesiaIndicated in advanced patients who are not being helped with there current therapy and have a significantly reduced level of functionSurgery does not cure and doesn’t help symptoms that aren’t or haven’t responded to dopaminergic therapy
11 Treatment of Parkinson’s Disease Symptomatic LevodopaMAO B inhibitorsDopamine agonists (ergot and non-ergot)COMT inhibitorsAnticholinergic agentsAmatadine
12 Treatment of Parkinson’s Disease Levodopa The most effective drug in the treatment of Parkinson’s diseaseIt helps the symptom of bradykinesia and rigidity best, will often help the tremor as wellPostural instability responds the leastIt is combined with a decarboxylase inhibitor
13 Treatment of Parkinson’s Disease Levodopa Immediate-release carbidopa/levodopa (Sinemet) – 10/100, 25/100, 25/250Parcopa is a immediate –release formulation that dissolves under the tongue.Sinemet CR is a controlled release formulation – 25/100 and 50/200
14 Treatment of Parkinson’s Disease Levodopa – Dosing Treatment is usually started with 25/100 immediate release ½ to 3 per day.Most patients get a response at mg per day of levodopaControlled release levodopa preparations usually require 30% more to achieve a clinically similar effect
16 Treatment of Parkinson’s Disease MAO B inhibitors Selegiline – Eldepryl (5mg AM )Rasagiline – Azilect (0.5mg – 1.0mg)Selegiline orally dissolving tablet - Zelapar ( mg)
17 Treatment of Parkinson’s Disease MAO B inhibitors Typically don’t produce a significant functional benefit. But is often used early in the disease course.These agents serve as an adjunct with levodopa. They may lessen development of motor fluctuations. Dyskinesias are not affected
18 Treatment of Parkinson’s Disease MAO B inhibitors Mortality was not increased in patients taking these agentsNausea, headache, confusion probably by enhancing the effects of levodopaPDR warns against the use of these agents with tricyclics and SSRI’sUnlike nonselective MAO inhibitors these agents don’t precipitate hypertensive crisis in patient who ingest high tyramine foods
19 Treatment of Parkinson’s Disease MAO B inhibitors SSRI’s and the risk of the serotonin syndrome is very rare if present at the standard doses of the current MAO B drugsSertraline is probably the safest SSRI to use. TCA’s are often used as well but be careful about anticholinergic side effects
20 Treatment of Parkinson’s Disease Dopamine Agonists BromocriptinePergolidePramipexoleRopiniroleApomorphine - Injectable
21 Treatment of Parkinson’s Disease Dopamine Agonists These are synthetic agents that directly stimulate the dopamine receptorThey were initially developed for adjunctive therapy with levodopa but can be used as initial therapyThey are very effective for use in patients who develop motor fluctuations and dyskinesias
22 Treatment of Parkinson’s Disease Dopamine Agonists Most patients who initially start on agonists will need to be on levodopa at some point.Pergolide (Permax) has been taken off the market, voluntarily by the manufacturerOral dopamine agonist need to be started slowly and the effect is not quick.
23 Treatment of Parkinson’s Disease Dopamine Agonists Patients on dopamine agonists may develop impulse control problemsThe adverse effects of dopamine agonist are similar to levodopa. Peripheral edema is more common with agonistsElderly and demented patients are more susceptible to psychiatric side effectsWarn patients about “sleep attacks”
24 Treatment of Parkinson’s Disease Dopamine Agonists Dopamine dysregulation syndrome – a cyclical mood disorder with hypomania and possible manic psychosisImpulse control disorders including hypersexuality and pathologic gambling may occur
26 Treatment of Parkinson’s Disease COMT Inhibitors These drugs are ineffective when used aloneUsed mainly in patients with wearing offTolcapone is associated with hepatotoxicity and is rarely used in the U.S.
27 Treatment of Parkinson’s Disease Anticholinergics Trihexyphenidyl (Artane)Benzotropine (Cogentin)
28 Treatment of Parkinson’s Disease Anticholinergics Most useful in patients with tremor predominate Parkinson's disease and age less than 65Do not use in patients with a Dementia
29 Treatment of Parkinson’s Disease Amantadine Probably has multiple mechanisms of actionIs used to treat symptoms of akinesia, rigidity, and tremor.Is often used to treat dyskinesias in patients already on levodopaSide effects include livedo reticularis, ankle edema, confusion and hallucinations
32 Treatment of Parkinson’s Disease Recommendations Either Carbidopa/Levodopa immediate release or a dopamine agonist can be used as initial therapy in patients who are functionally impaired.Levodopa preparations are the most effective agents for the treatment of Parkinson's diseaseIt is reasonable to initiate therapy with a dopamine agonist in younger patients
33 Treatment of Parkinson’s Disease Recommendations Pergolide (Permax) should be avoidedAnticholinergics can be used in younger (65 or less) tremor predominate patients.MAO B inhibitors produce a symptomatic benefit that is mild and these agents are often used early in the treatment of Parkinson patients.
34 Treatment of Parkinson’s Disease Recommendations Surgery for Parkinson's disease is a reasonable treatment in selected patients