Thursday, March 11, 2010

Parkinson's disease

Parkinson's disease - Chronic
Rahul Soman, M. Pharm


 

Definition  

A chronic, progressive, neurodegenerative condition that generally affects adults in middle to late life and is characterized by bradykinesia, tremor, rigidity, gait disturbances, and postural instability


 

Medical History  

* Family history of Parkinson's disease

* Gaucher's disease

* Ashkenazi Jew or North African Arab heritage

* Postconcussion syndrome

* Parkinson Associated Risk Syndrome


 

Findings  

* Resting tremor

* Bradykinesia

* Muscle rigidity

* Pain

* Agnosia for smell

* Difficulty controlling posture

* Festinating gait

* Sleep disorder - Chronic

* Difficulty writing

* Shuffling gait

* Falls

* Anxiety

* Dysphoric mood

* Dysarthria

* Expressionless face

* Decreased blinking

* Cogwheel eye movements

* Freezing of gait

* Parkinsonian flexion posture

* Drooling

* Difficulty swallowing

* Constipation - Chronic

* Orthostatic hypotension

* Sexual dysfunction

* Bladder control - finding

* Impaired cognition

* Dementia

* Unintentional weight loss - Chronic


 

Tests  


 

Suspected familial Parkinson disease  

* Genetic test


 

Suspected atypical Parkinson disease when difficult to diagnose, or Parkinson disease with dementia, or to differentiate Parkinson disease from multiple system atrophy  

* MRI of head: No specific MRI findings are found with idiopathic Parkinson disease; however, MRI may be useful to detect various abnormalities that occur with other forms of parkinsonism .


 

Differential Diagnosis  

* Essential tremor

* Parkinsonism due to drug

* Vascular parkinsonism

* Progressive supranuclear ophthalmoplegia

* Multiple system atrophy

* Corticobasal degeneration

* Senile dementia of the Lewy body type

* Neoplasm of brain

* Normal pressure hydrocephalus

* Psychogenic factor


 

Treatment  


 

Drug Therapy  


 

Motor impairment associated with Parkinson disease  


 

CARBIDOPA/LEVODOPA  

Adults: Carbidopa 25 mg/levodopa 100 mg combination, 1 tablet orally 3 times daily; increase by 1 tablet daily or every other day up to a maximum of 8 tablets (200 mg carbidopa) daily


 

CARBIDOPA/LEVODOPA/ENTACAPONE  

Adults: Carbidopa 12.5 mg/levodopa 50 mg/entacapone 200 mg combination OR carbidopa 25 mg/levodopa 100 mg/entacapone 200 mg combination OR carbidopa 37.5 mg/levodopa 150 mg/entacapone 200 mg combination OR carbidopa 50 mg/levodopa 200 mg/entacapone 200 mg combination: 1 tablet orally per dose, titrate to desired response; maximum is 6 tabs (1200 mg levodopa) daily


 

Dopamine agonists for initial treatment of Parkinson disease or as adjunctive therapy with levodopa  


 

PRAMIPEXOLE DIHYDROCHLORIDE  

Adults: Initial dose 0.125 mg orally 3 times daily, titrate up to a maximum dose of 4.5 mg per day


 

ROPINIROLE HYDROCHLORIDE  

Adults: Initial dose 0.25 mg orally 3 times daily, gradually increase to a total of 9 mg to 24 mg per day based on clinical response


 

BROMOCRIPTINE MESYLATE  

Adults: Initial dose 1.25 mg orally twice daily; increase by 2.5 mg daily every 14 to 28 days; usual maintenance dose range 2.5 to 40 mg/day orally

Adult: Initial dose 0.8 mg orally once daily, increase by 0.8 mg/week as tolerated up to maximum of 4.8 mg/day


 


 

MAO-B inhibitors for initial treatment of Parkinson disease or as adjunctive therapy with levodopa  


 

RASAGILINE

Adults: Initial dose 0.5 mg to 1 mg orally once daily


 

SELEGILINE HYDROCHLORIDE  

Adults: 5 mg to 10 mg orally once daily OR 2.5 mg orally once daily when added to levodopa

Adults (oral disintegrating tablet): Initial dose of 1.25 mg orally dissolved on the tongue once daily for at least 6 weeks; maintenance dose 2.5 mg orally dissolved on the tongue once daily


 


 

Catechol-O-methyltransferase (COMT) inhibitors used as adjunctive therapy in the treatment of Parkinson disease  


 

ENTACAPONE  

Adults: 200 mg orally with each dose of levodopa


 

TOLCAPONE  

Adults: 100 mg or 200 mg orally 3 times daily


 


 

Anticholinergic therapy used as monotherapy or as adjunctive therapy with levodopa in the treatment of Parkinson disease  


 

AMANTADINE HYDROCHLORIDE  

Adults: 100 mg orally twice daily; may titrate up to 300 mg per day in divided doses


 

Anticholinergic therapy for resting tremor in younger patients with Parkinson disease  


 

BENZTROPINE MESYLATE

Adults: Initial dose 0.5 mg to 1 mg orally once daily at bedtime; adjust dose as needed up to 6 mg/day


 

TRIHEXYPHENIDYL HYDROCHLORIDE  

Adults: Initial dose 0.5 mg to 1 mg orally twice daily; gradually increase to 1 mg to 2 mg orally 3 times daily as tolerated


 

Rescue therapy for patients with Parkinson disease during severe "off" periods  


 

APOMORPHINE HYDROCHLORIDE  

Adults (test dose to determine the appropriate treatment dose): 2 mg subQ in a setting where supine and standing blood pressure can be closely monitored at baseline and at 20-, 40- and 60-minutes post-dose intervals while patient is in a "off" state; THEN 2 mg to 6 mg subQ as needed for "off" episodes, maximum is 1 dose/episode and no more than 5 times/day or 20 mg/day


 

Depression associated with Parkinson disease  


 

AMITRIPTYLINE HYDROCHLORIDE  

Adults: 75 mg orally in divided doses; may increase up to a maximum of 150 mg/day OR 50 mg to 100 mg orally at bedtime; may increase in 25 mg to 50 mg increments until maximum dose of 150 mg/day


 

FLUOXETINE HYDROCHLORIDE  

Adults: 20 mg to 40 mg orally once daily


 

PAROXETINE HYDROCHLORIDE  

Adults: 20 mg to 40 mg orally once daily


 

SERTRALINE HYDROCHLORIDE  

Adults: 50 mg to 150 mg orally once daily


 

Psychosis in patients with Parkinson disease  


 

QUETIAPINE FUMARATE  

Adults: 12.5 mg orally once daily at bedtime, increase as needed at 3-day to 5-day intervals until desired effect or side effects manifest


 

CLOZAPINE

Adults: Initial dose 6.25 mg to 12.5 mg orally once daily at bedtime, increase every 3 to 5 days as needed to 25 mg to 75 mg/day until desired effect


 

Impaired cognition and dementia in patients with Parkinson disease  


 

DONEPEZIL HYDROCHLORIDE  

Adults: tablets or solution, 5 mg or 10 mg orally once daily at bedtime, with or without food OR orally disintegrating tablets, 5 mg or 10 mg dissolve orally on the tongue once daily


 

RIVASTIGMINE TARTRATE  

Adults: initial, 1.5 mg orally twice daily with meals; based on tolerability, may increase dose by 1.5 mg/dose up to 6 mg orally twice daily, with a minimum of 4 weeks at each dose


 

Procedural Therapy  


 

Severe and disabling Parkinsonian tremor unresponsive to medical therapy  

* Deep brain stimulation: Deep brain stimulation may be an effective surgical treatment for patients with Parkinson disease whose motor symptoms cannot be adequately controlled with medical therapy .

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SYSTEM BASED CLASSIFICATION OF DISEASES

SYSTEM BASED CLASSIFICATION OF DISEASES

Bone and Joint Diseases

  1. Gout and Hyperurecemia
  2. Osteoarthritis
  3. Rheumatoid Arthritis
  4. Acute coronary Syndroms

Cardiovascular Diseases

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  2. Cardiopulmanary Resuscitation
  3. Heart Failure
  4. Hypertension
  5. Hyperlipidemia
  6. Ischemic Heart Diseases
  7. Shock
  8. Stroke
  9. Venous Thromboembolism

Dermatrologic Diseases

  1. Acne
  2. Psoriasis
  3. Skin Disorders and Cutaneous Drug Eruptions

Endocrine Diseases

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  2. Portal Hypertension

Gastrointestinal Diseases

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  2. Constipation
  3. Diarrhea
  4. Gastroesophagal Reflux Disease
  5. Hepatitis, Viral
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    3. Hepatitis C
  6. Nausea and Vomiting
  7. Pancreatitis
  8. Peptic Ulcer disease

Gynecologic and Obstetric Diseases

  1. Contraception
  2. Hormone therapy

Hematologic Diseases

  1. Anemia
    1. Megaloblastic Anemia

i. Megaloblastic Anemia due to Folate Deficiency

ii. Megaloblastic Anemia due to Vitamine B12 Deficiency

    1. Sickle Cell anemia
    2. Hemolytic Anemia
    3. Iron Deficiency Anemia
    4. Aplastic Anemia
    5. Iron Deficiency Anemia

Infectious Diseases

  1. Central Nervous System infections
  2. Endocarditis
  3. Fungal infections, Invasive
  4. Gastrointestinal Infection
  5. HIV / AIDS
  6. Intra-Abdominal Infection
  7. Respiratory Tract infections, Lower
  8. Respiratory Tract infections, Upper
  9. Sepsis and Septic Shock
  10. Sexually transmited Diseases (STD)
  11. Skin and soft tissue infection
  12. Tuberculosis
  13. Urinary tract infection and prostatitis

Neurologic Diseases

  1. Epilepsy
  2. Headache
    1. Migraine
    2. Cluster Headache
  3. Pain management
  4. Parkinson’s Diseases
  5. Status epilepticus

Nutritional Diseases

  1. Enteral Nutrition
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  1. Breast cancer
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Ophtalmic Diseases

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Psychiatric Diseases

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Renal Diseases

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  4. Drug Dosing in renal insufficiency
  5. Electrolyte Homeostasis

Respiratory Diseases

  1. Allergic Rhinitis
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Urologic Diseases

  1. Benign Prostatic, Hyperplasia
  2. Erectile Dysfunction
  3. Urinary Incontinence