Download 03 Motor Symptoms PD SLIDES

Management of Parkinson‟s disease
Treatment of motor symptoms
Learning Objectives
• List the common medications used to treat the
motor symptoms of Parkinson‟s disease and the
adverse effects associated with their use
• Demonstrate an understanding of the treatment
pathways for early and advanced disease
• Describe the role of non-pharmacological and
complementary treatment in disease
management
Pharmacological treatment
• Aim to improve motor and non-motor symptoms
• Individually tailor medication
• Medication aims to:
– increase level of available dopamine in the brain
– stimulate parts of the brain where dopamine works
– block the action of other chemicals that affect
dopamine
• As disease progresses number of medications
needed will increase and adjustments become
more common
When to start drug treatment
• Based on:
– age of patient
– severity of symptoms
– likelihood of adherence
– cognitive impairment
– co-morbidities
– patient wishes
Levodopa
Low levels of
dopamine makes
movement difficult
Levodopa is
converted into
dopamine in the brain
and gut
Levodopa increases
the level of dopamine
in the brain allowing
movement to be
restored.
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Levodopa – dosing and dose forms
Form
Immediate release
Name
Sinemet, Madopar,
Kinson,
Levo/Carbidopa
Controlled release (CR) Sinemet CR
Dispersible tablets
Madopar Rapid
Gel (intestinal)
Duodopa
Combined with COMT Stalevo
Levodopa – adverse effects
Adverse effects
How to combat them
Nausea and vomiting
May require an antiemetic e.g
domperidone (Motilium)
Constipation
Alteration to diet; laxative use
Hypotension ( low blood pressure)
Stand up and change position slowly to
avoid falling
Increased lethargy
Involvement in a balanced activity/rest
program
Nightmares/hallucinations/ confusion
May require some medication adjustment
Dyskinesia (involuntary movements)
usually associated with long term use
May require some medication adjustment
and/or additional medication
Prolonged use of levodopa
Fluctuations
Dyskinesias
•
•
•
•
Wearing OFF
Delayed ON
ON-OFF swings
Freezing
• Involuntary erratic
movements affecting the
face, arms, legs and trunk
Dopamine agonists
Dopamine agonists
Apomine (apomorphine hydrochloride)
Cabaser; Bergoline (cabergoline)
Neupro (rotigotine)
Permax (pergolide mesylate)
Parlodel ; Kripton (bromocriptine mesylate)
Sifrol (pramipexole)
Action
Mimic the action of Dopamine in the brain making movement
easier
Use
Early stages of PD – Monotherapy as less likely to cause
dyskinesias than Levodopa
Later stages of PD - Additional treatment with levodopa
Dosage forms
Extended release tablets, transdermal patch, subcutaneous
injection or continuous subcutaneous infusion
Adverse effects
Nausea, hallucinations, sedation, light headedness,
compulsive behaviours
MAO-B inhibitors
MAO-B
inhibitors
Selegiline hydrochloride (Selgene, Eldepryl )
Action
Inhibits enzyme responsible for dopamine metabolism,
leading to elevated dopamine levels in the brain
Use
Early stage of PD - delay the need for levodopa although
rarely used alone
Later stage of PD - to boost the effects of levodopa and
prevent “wearing off”
Dosage form
tablet
Adverse effects
Insomnia, hallucinations and jitteriness
COMT inhibitors
COMT
inhibitors
Entacapone (Comtan )– taken with Levodopa
Levodopa/carbidopa/entacapone (Stalevo)
Action
Increases amount of Levodopa entering the
brain by preventing metabolism in the periphery
Use
Given with Levodopa; helps with the problem of
„wearing off‟.
Dosage form
Tablet 200mg
Adverse
effects
Vivid dreams, hallucinations, sleep disturbances,
daytime drowsiness, headaches and
dyskinesias; discolouration of body fluids (bright
yellow/orange) and diarrhoea
Anticholinergics
Anticholinergics
Benzhexol hydrochloride (Artane)
Benztropine mesylate (Cogentin)
Biperiden hydrochloride (Akineton)
Orphenadrine (Norflex)
Action
Correct the imbalance between two
neurotransmitters in the brain, dopamine and
acetylcholine
Use
Useful in the treatment of tremor but may also
address bradykinesia, rigidity and sialorrhea in the
younger people with PD
Dosage form
Tablet
Adverse effects
Dry mouth, urinary retention, blurred vision and
confusion (especially in the older people with PD)
Amantadine
Amantadine
Amantadine hydrochloride (Symmetrel )
Action
Increases dopamine release and blocks
cholinergic receptors
Use
Used as an additional treatment to levodopa;
useful in reducing dyskinesias (abnormal
movements)
Dosage form
Capsules
Adverse
effects
Insomnia, confusion and a mottled rash on the
lower limbs.
Long term treatment of PD
Early PD
• Diagnosis
• Monotherapy
based on
patient factors
i.e. Dopamine
agonist
Therapy
adjustments
• Addition of
levodopa
therapy to
enhance
symptom
control
• Adjunctive
therapy with
MAO-inhibitor
Advanced PD
• Treatment of
non-motor
symptoms
• COMTinhibitor
added to
reduce
levodopa
motor
complications
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Complementary treatment
•
•
•
•
•
Creatinine
Vitamins C and E
Vitamin D
Vitamins B6,B12 and folate
Coenzyme Q10
Non-drug treatments
•
•
•
•
Regular exercise
Balanced diet
Speech therapy
Intervention by occupational
therapists
• Education and counselling
Surgical options
• Thalamotomy
• Pallidotomy
• Deep brain
stimulation
What a patient needs to know
•
•
•
•
•
What the medication is for?
What benefits should be expected?
Possible side effects and their management
Drug interactions
Detailed drug record
Case study
• Admitted to ACF
– Sinemet 275mg tds
• Poorly controlled PD;
hallucinations; falls
• PD was reviewed by
neurologist
• Sinemet reduced to 62.5mg
tds with the use of the
controlled release
formulation at night.
Summary
• All patients with PD will ultimately require
pharmacotherapy
• Aim of treatment of motor symptoms is to restore
dopamine levels
• Treatment choice will depend on age, symptoms, comorbidities and patient wishes
• As disease progresses the number of medications and
adjustments required will increase
• It is extremely important that medications are managed
well and given on time to reduce motor symptoms
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