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 .