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carbidopa/levodopa (Sinemet/Parcopa)
dopamine agonists
Why is pt receiving this? First line treatment for Parkinson’s Disease, not useful w/ extrapyramidal.
Levadopa converted to dopamine in CNS by L acromatic amino acid decarboxylase. Carbidopa inhibits
decarboxylase, prevents periph destruction of levodopa
Dosage av ER, PO: 25 mg carb/100mg 3x daily,
SE CNS: Involuntary movements, hallucinations, psychosis, urges (gambling/sexual) GI: n/v, darken
sweat/urine, hepatotoxicity DERM: activates melanoma
Data used to indicate med is effective/goal assess Parkinson’s symptoms, BP/pulse frequently, liver
funct tests, GOAL: alleviation of Parkinson’s symptoms
Med Administration Concerns “On/off” phenomenon, administer on regular schedule, drug is only
effective for limited amount of time (2-5 years) and may exacerbate motor symptoms, hypertensive
crisis when used with MAOI’s; only limited dosages available; does not treat nonmotor symptoms
pt teaching points take as prescribed, gastric irritation may be alleviated w/ food shortly following med,
should eat with low protein meal to prevent competing absorption of levodopa; eye and muscle
twitching early sign of toxicity
pramipexole (Mirapex)
Non ergot dopamine agonist
Why is pt receiving this? mgmt. of Parkisnon’s disease and RLS. Used alone and early in Parkinson’s
(Levadopa saved for advanced PD). Doesn’t depend on enzymatic conversion, doesn’t compete w/
dietary proteins.
Dosage ER available; .125 mg 3 times daily initially, may be increased q 5-7 days
w/ renal impairment CCr 35-39 mL/min/ .125 mg bid, “
”
SE SLEEP ATTACKS hallucinations, sedation , day sleepiness, insomnia, constipation (w/ combination
use: dyskinesias, orthostatic hypotension) impulse control disorder (rare), SIADH
Data used to indicate med is effective/goal assess for LOC, confusion/hallucinations, ECG/BP,
drowsiness/sleep attacks, s/sx of PD GOAL: decreased tremor and rigidity in PD
Med Administration Concerns cimetidine decreases renal excretion (increases levels), use w/ levadopa
increases risk of hallucinations/dyskinesia ; administer w/ meals to minimize nausea
pt teaching points medication takes several weeks to develop, lower incidence of response failure, may
cause drowsiness, attacks of sleep; change position slowly to avoid orthostatic hypotension (fall risk
protocol), alert if new or increased urge to gamble or have sex
entacapone (Comtan)
catechol-O-methyltransferase (COMT) inhibitors
Why is pt receiving this? w/ levadopa/carbidopa to treat idiopathic PD when s/sx of end of dose
wearing off occurs; inhibits metabolism of levadopa in intestines/periph tissues->decreases production
of metabolites that compete w/ levadopa for transport; increase availability of levadopa
Dosage 200 mg PO wth each dose of levodopa/carbidopa up to max of 8 times a day
SE ADVERSE EFFECTS FROM INCRES LEVODOPA LEVELS (dyskinesia, nausea, confusion, sleep disorders,
hallucinations, hypotension, abd pain, impulse control) ENCANTROPONE ALONE: orange urine,
vomiting, diarrhea/constipationNEUROLEPTIC MALIGNANT SYNDROME, RHABDO
Data used to indicate med is effective/goal Assess PD and extrapyramidal s/sx, monitor for s/sx of
diarrhea or MNS
Med Administration Concerns ALWAYS ADMINISTER W/ LEVADOPA;
pt teaching points take as directed and taper when discontinuing, may cayse dizziness / hallucinations,
nausea/diarrhea may occur (encourage fluids), change position slowly to minimize orthostatic
hypotension (fall risk precautions),
benztropine (Cogentin)
anticholinergic
Why is pt receiving this? adjunctive treatment of all forms of PD incl. drug induced extrapyramidal effects and acute
dystonic rxns; blocks cholinergic effects in brain restoring neurotransmitter balance
Dosage PO 1-2 mg/day in 1-2 divided doses
Drug induced extrapyramidal reactions: PO,IV, IM 1-4 mg given once or twice daily (IV rarely used, rate: 1 mg/min)
SE confusion, depression, dizziness, hallucinations, blurred vision, dry eyes, constipation, drymouth, ATROPINE
(parasympatholytic) effects: hypotension, tachycardia, arrhythmias, inability to sweat, urinary retention, possible
disorientation
Data used to indicate med is effective/goal Assess for parkinsonian and extrapyramidal rxns, assess bowl function daily
(monitoring for constipation, abd pain, distension or absence of bowel sounds), monitor Is and Os and assess for urinary
retention, pts w/ mental illness at risk of exacerbation of symptoms, GOAL: improve muscle rigidity and tremor but have
little effect on bradykinesia
Med Administration Concerns contraindicated in pts w/ hypersensitivity/tardive dyskinesia; additive anticholinergic
effects, antacids/antidiarrheals can affect absorption; THIS and trihexiphenidyl (Artane) on BEERS list
pt teaching points take as directed (take missed doses within 2 hrs of next dose if remembered), may cause
drowsiness/dizziness: avoid driving or other focused tasks until tolerance of drug understood, good oral
hygiene/frequent sips of water/sucking on sugarless hard candy can alleviate dry mouth, change positions to minimize
orthostatic hypotension (fall risk protocol), may decrease perspiration so overheating can occur, avoid taking
antidiarrheal/antacids w/in 2 hrs
selegiline (Eldepryl)
MAO-B (dopamine metabolizer) inhibitor
Why is pt receiving this? Mgmt of PD w/ levodopa or levodopa/carbidopa in pts who fail to respond to
levodopa alone; selectively, irreversibly binds to MAO-B to prevent breakdown of dopamine and prolong
effects of levodopa
Dosage 5 mg twice daily with breakfast and lunch, orally disintegrating tabs: 1.25 mg once a day for 6
weeks
SE confusion, dizziness, faintain, hallucinations (can last for months), insomnia, urges, vivid dreams,
melanaoma, nausea, abd pain, dry mouth; HIGH DOSES CAN RESULT IN HTN CRISIS
Data used to indicate med is effective/goalassess for PD s/sx and BP throughout therapy, GOAL:
Med Administration Concerns contraindicated in concurrent use of opioid analgesics, SSRIs, or tricyclic
depressants, hypersensitivity; MUST discontinue use of antidepressants 2-7 weeks before, use with
opioids can result in fatal hyperthermia, tyramine foods can cause hypertensive crisis , administer w/
breakfast or lunch
pt teaching points AVOID tyramine containing foods (aged/fermented/high protein; tyramine is
metabolized by MAOA; metab compromised by MAOIs, tyramine can release norepi, epi, and dopamine
resulting in hypertensive crisis), inform pt of signs of MAOI induced hypertensive crisis and the
importance of alerting HCP, caution pt to change position slowly to avoid orthostatic hypotension (fall
risk precautions)
Amantadine
Antiviral
Why is pt receiving this? symptomatic initial and adjunct treatment of Parkinson’s Disease, potentiates action of
dopamine in CNS (unknown mechanism)
Dosage 100 mg 1-2 times daily (up to 400 mg daily) PO
SE ataxia, dizziness, insomnia, anxiety, confusion, depression, urges, dry mouth, n/v, anorexia, constipation,
dyspnea, hypotension, HF, edema, urinary retention, molting, “livedo reticularis” (discoloration), melanoma,
leukopenia, neutropenia
Data used to indicate med is effective/goalassess BP periodically for drug induced orthostatic hypotension,
monitor vital signs and mental status during first few days of dose adjustment, assess for HF, monitor Is and Os
closely in geriatric pts, assess PD s/sx and symptoms of toxicity (CNS stimulation) GOAL: decrease in akinesia and
rigidity
Med Administration Concerns contraindicated in hypersensitivity, use cautiously w/ seizure disorders, liver
disease, HF, renal impairment ; additive anticholinergic effects, increased risk of CNS rxns with alcohol, CNS
stimulation with other stimulatns; Do not administer last dose before bedtime (may cause insomnia); dividing dose
into smaller doses may decrease CNS side effects, contents of capsule MAY be mixed with food or fluids in pts w/
dysphagia
pt teaching pointsTake med as scheduled, do not double up or take missed doses w/in 4 hours of next dose, may
cause dizziness or blurred vision (avoid driving until rxn to med understood), change position slowly to minimize
orthostatic hypotension (fall risk protocol), water/hard candy/oral hygiene to counteract dry mouth, UP TO 2
WEEKS OF THERAPY MAY BE NEEDED FOR FULL BENEFIT OF MED
donepezil (Aricept)
Anti-Alzheimer’s agents; cholinergic (cholinesterase
inhibitor)
Why is pt receiving this? mild, moderate, or severe dementia/neurocognitive disorder associated w/ Alzheimer’s
disease (USED EARLY); inhibits acetylcholinesterase thus improving cholinergic function by making more
acetylcholine vailable
Dosage PO 5 mg once daily; may increase to 10 mg once daily after 4-6 weeks, after 3 mo may increase to 23
mg/day
SE HA, abnormal dreams, depression, insomnia, syncope, sedation, A fib, hyper/hypotension, vasodilation,
bradycardia, dyspepsia, diarrhea, n/v, anorexia, frequent urination, bronchoconstriction
Data used to indicate med is effective/goal assess cognitive function, monitor HR periodically for bradycardia
Med Administration Concerns can take w/ food to alleviate GI upset, interfers w/ action of anticholinergics, can
increase risk of GI bleed w/ NSAIDs, phenobarb and phenytoin induce CYP450 enzymes that increase excretion of
donepezil (decreased effect)
pt teaching pointsEmphasize importance of adhering to medication regiment, omit missed doses and return to
schedule the following day; drug effects may take weeks, may cause dizziness, alert HCP for abdominal symptoms
memantine
Anti-Alzheimer’s, N-methyl-D-aspartate (NMDA)
antagonist
Why is pt receiving this? Moderte to severe dementia/neurocognitive disorder assoc. w/ Alzheimers,
binds to NMDA preventing binding of glutamate (excitatory neurotransmitter) and release of calcium (In
AD, damaged/tangled cells can overproduce glutamate, which can lead to constant exposure to calcium damaging
neurons further), DOES NOT SLOW OR STOP dementia but enhances cognitive function
Dosage PO: IR: 5 mg once daily initially, increase at weekly intervals to 10 mg/day (5 mg twice daily), then 15 mg
(5 mg once daily, 10 mg once daily as separate doses), then to target dose of 20 mg/day (10 mg twice daily); ER: 7
mg once daily, increase at weekly intervals by 7 mg/day to target dose of 28mg once daily
IMPAIRED RENAL FN: IR target dose is 10 mg/day (5 mg twice daily), ER: 14 mg/day
SE dizziness, HA, confusion, constipation, hallucination, hypertension, weight gain, anemia
Data used to indicate med is effective/goal Assess cognitive function periodically GOAL: improvement
in neurocognitive decline (memory, attention, reasoning, language, ability to perform simple tasks)
Med Administration Concerns administered without regard to food, DO NOT CRUSH ER,
pt teaching points instruct caregiver when/how to administer and how to titrate dose, caution may
cause dizziness, improvement in cognitive function may take MONTHS (degenerative process is not
reversed)