NeuroCare Institute of Central Florida Winter Park FL 32792 Clinical Assistant Professor of Medicine Neurology Florida State University College of Medicine Cardinal Features of Parkinsons Disease ID: 779961
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Slide1
2016 MOVEMENT DISORDERS
Hal S. Pineless, D.O., FACN
NeuroCare
Institute of Central Florida
Winter Park, FL 32792
Clinical Assistant Professor of Medicine (Neurology)
Florida State University College of Medicine
Slide2Cardinal Features of Parkinson’s Disease
Bradykinesia
Postural instability
Truncal rigidity
Resting Tremor
Slide3Parkinson’s Disease Treatments
Carbidopa/levodopa
Dopamine Agonists
COMT inhibitors; MAO-B inhibitors
Amantadine and anticholinergics
Deep Brain Stimulator (DBS)
Slide4Anticholinergics
Not used much today due to side effects (poor cognition, dementia)
Great for treating Parkinson resting tremors
Trihexyphenidyl
(
Artane
) 2 mg TID is usual dose
Used in psychiatry for tardive
dyskinesias
Slide5Carbidopa/levodopa
Still the gold standard in treating PD, even after all these years
Available in regular, ER/CR, enteral formulations
Hallucinations, orthostatic hypotension, GI,
dyskinesias
are SE
Carbidopa/levodopa ER (
Sinemet
CR) 25/100, 50/200
Carbidopa/levodopa (
Sinemet
) 10/100, 25/100, 25/250
Rytary
–ER formulation given TID—dose varies
Slide6Dopamine Agonists
Pramipexole
and
ropinirole
are the most common ones used today
Pramipexole
(Mirapex): Available in regular (TID) and ER form
Ropinirole
(
Requip
): Available in regular (TID) and XL form
Maximum dose of
pramipexole
is 4.5 mg daily
Maximum dose of
ropinirole
is 24 mg daily
Rotigotine
patch (
Neupro
)—maximum dose is 8 mg/24 hours
Rotigotine
patch dose=
ropinirole
dose=1/4 for
pramipexole
dose
Compulsive behaviors and
hypersexuality
notable side effects
Slide7COMT Inhibitors
Entacapone
(
Comtan
) 200mg is the most common one used
Used to enhance effectiveness of carbidopa/levodopa
Can’t be used without carbidopa/levodopa
Give at same time as carbidopa/levodopa
Orange colored urine is side effect
Similar side effects as carbidopa/levodopa
Ticlopidine
200 mg TID can be used, but aplastic anemia is risk
Slide8MAO-B Inhibitors
Rasagaline
(
Azilect
) and
Selegiline
(
Eldepryl
,
Zelpar
)
Rasagaline
0.5 mg initially, then 1 mg q AM thereafter
Rasagaline
doesn’t raise BP;
selegiline
might raise BP due to amphetamine
metabolities
Neuroprotective?
Can be used initially or
adjuctive
in treatment of PD
Interaction with SSRIs causing serotonin syndrome is theoretical!
Slide9Amantadine
Amantadine 100 mg BID-TID
Useful for postural instability (imbalance) in PD
Helpful with PD tremors
Has antiviral properties (flu prevention)
Can be used for MS related fatigue
Biggest side effect is visual hallucinations
Slide10Deep Brain Stimulation (DBS)
Used in medically refractory cases of PD. Should be used sooner?
Great with treating tremors (Parkinson and BET)
Useful with rigidity, bradykinesia,
dyskinesias
Avoid in Parkinson-Plus syndromes, psychotic patients, alcoholics
Levodopa Effect=DBS effect
Use with caution in dementia patients
Slide11How I Treat Parkinson’s Disease
Exercise 30 minutes daily at least 5 days a week
Over age 75: Carbidopa/levodopa ER 25/100 TID to start. Add
entacapone
later if needed before increasing carbidopa/levodopa. May use
rasagaline
before instituting carbidopa/levodopa or later in therapy. Dopamine agonist? Amantadine if imbalance or bad tremors.
Under age 75:
Rasagaline
? Carbidopa/levodopa ER 25/100 TID to start. Add dopamine agonist. Push dopamine agonist to toxicity.
Entacapone
. Amantadine if imbalance or bad tremors. DBS?
Movement disorder tertiary center?
Slide12Parkinson-Plus Syndromes
Lewy Body Disease/Dementia=Dementia with Lewy Bodies (LBD)
Progressive
Supranuclear
Palsy (PSP)
Multisystem Atrophy (MSA)
Corticobasal
degeneration (CBD)
Not responsive to anti-PD drugs
Slide13Lewy Body Dementia (LBD)
Sometimes classified as a dementia (ICD-10)
Progressive cognitive decline with EPS
Visual hallucinations early in disease are pathognomonic
Slide14Progressive Supranuclear
Palsy (PSP)
Also known as Steele-Richardson-
Olszewski
syndrome
Frequent falls
Impaired vertical gaze, especially downward gaze
Emotional and personality changes, like PBA
Slide15Multisystem Atrophy (MSA)
Formerly known as Shy-
Drager
Syndrome
Characterized by symptoms of ANS failure
Lightheadedness, syncope, constipation, ED, urinary retention
EPS, dysarthria
Loss of muscle coordination
Check for orthostatic hypotension in the office
Slide16Corticobasal Degeneration (CBD)
Main symptom is apraxia (inability to perform coordinated movements or use familiar objects)
Pronounced asymmetry
Stiffness that is worse than PD
Myoclonus (twitching or jerking), usually in the hand
Slide17Benign Essential Tremors
Also known as benign familial tremors
Primidone and propranolol/propranolol ER effective treatments
Primidone 50-100 mg daily; push to toxicity
Propranolol 80-320 mg/d: watch for BP < 90/50 or HR < 50
Alcohol improves tremors, but alcoholism worsens tremors
Weighted kitchen utensils, pens help decrease tremors
Bronchodilators, stress, CNS stimulants increase tremors
Alprazolam,
topiramate
, gabapentin, clonazepam, DBS probably work
Slide18Cervical Dystonia (Spasmodic Torticollis)
Involuntary contractions of the shoulders and neck causing abnormal postures or movements of the neck, shoulders and head
Treatment of choice:
onabotulinumtoxinA
(Botox);
rimabotulinumtoxinB
(
Myobloc
);
abobotulinumtoxinA
(
Dysport
)
Antipsychotic and
antinausea
meds might trigger cervical dystonia
Prototype: female; aged 40-70; family history positive for it
Other treatments: anti-PD drugs, pain meds, muscle relaxants, PT
Selective denervation surgery; DBS in very rare cases
Slide19Wilson’s Disease
Rare, inherited disorder causing high copper in organs (liver, brain)
Symptoms start in ages 12-23
Low serum
ceruloplasmin
, high copper levels
Signs & symptoms: fatigue, decreased appetite, abdominal pain, jaundice, edema, dysarthria, dysphagia, EPS, muscle stiffness, depression, personality changes, psychosis
Kayser
-Fleischer rings (golden brown discoloration) on eyes
Hereditary: ATP7B gene
Treat with
penicillamine
,
trientine
, zinc acetate, liver transplant
Slide20Kayser-Fleischer Ring
Slide21Tourette’s Syndrome
Developmental disorder that begins in childhood and teenage years
Chartacterized
by motor and vocal tics
ADHD and OCD often accompany Tourette’s
No cure, but there are treatments
Treatments: haloperidol,
pimozide
, clonidine, behavioral therapy
Slide22Huntington’s Disease (HD)
G
enetic disorder causing breakdown of neurons in the brain, causing death 15-20 years after diagnosis
Symptoms appear in ages 30-50, but can be earlier or later
Chorea, abnormal body postures, behavioral changes, dementia, personality changes, dysarthria, dysphagia
Caused by mutation in huntingtin gene that cause cytosine, adenine, and guanine (CAG) building blocks of DNA to repeat more times than normal. Each child of a parent with HD has a 50% chance of inheriting the HD gene.
Treatment:
tetrabenazine
,
deutetrabenazine
for HD chorea