slide 1 mosby items and derived items © 2007, 2004 by mosby, inc., an affiliate of elsevier inc....

Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

Chapter 15Chapter 15Drugs Used for Parkinson’s Disease


Chapter 15Chapter 15

Lesson 15.1Lesson 15.1


Learning ObjectivesLearning Objectives

• Prepare a list of signs and symptoms of Parkinson’s disease and accurately define the vocabulary used for the pharmacologic agents prescribed and the disease state

• Name the neurotransmitter that is found in excess and the neurotransmitter that is deficient in people with parkinsonism


Learning Objectives (cont’d)Learning Objectives (cont’d)

• Describe reasonable expectations of medications prescribed for treatment of Parkinson’s disease

• Identify the period necessary for a therapeutic response to be observable when drugs used to treat parkinsonism are initiated



• Name the action of bromocriptine, carbidopa, levodopa, entacapone, and apomorphine on neurotransmitters involved in Parkinson’s disease


Parkinson’s DiseaseParkinson’s Disease

• Chronic progressive disorder of CNS• 2nd most common neurodegenerative disease

after Alzheimers• Characteristic symptoms

Muscle tremors, slowness in movement (bradykinesia), muscle weakness with rigidity, alteration in posture and equilibrium

• Due to dopamine deficiency in extrapyramidal system within basal ganglia of brain

Extrapyramidal system• For maintaining posture and muscle tone and

regulating voluntary smooth muscle activity


Parkinson’s DiseaseParkinson’s Disease

• Neurotransmitters Dopamine (inhibitory) Acetylcholine (excitatory)

• Deficiency of dopamine leads to ACh activity leading to symptoms of Parkinsonism

• Types of parkinsonism Primary (idiopathic)

• Due to reduction in dopamine-producing cells in basal ganglia

Secondary (induced by head trauma, infection, tumors, or drug exposure)

• Due to head trauma, intracranial infections, tumors and drug exposure


Drug Therapy for Parkinson’s Drug Therapy for Parkinson’s DiseaseDisease

• Goal of treatment is minimization of symptoms, no cure for disease

• Individualized combination therapy• Therapy begins when symptoms interfere with ability

to function in daily life• All symptoms cannot be eliminated because of side

effects involved• Drug therapy

Selegiline to slow deterioration of dopaminergic nerve cells

Bromocriptine, carbidopa-levodopa, entacapone in combination to enhance dopaminergic activity

Anticholinergic to inhibit excess in cholinergic activity


Parkinson’s Disease Parkinson’s Disease DiagnosisDiagnosis

• Signs Facial appearance Psychological involvement

• Symptoms Motor function

• Tremor• Dyskinesia; propulsive, uncontrolled movement• Bradykinesia, akinesia

Excess salivation


Nursing Process for Nursing Process for Parkinson’s Disease TherapyParkinson’s Disease Therapy

• Assessment Unified Parkinson’s Disease Rating Scale

(UPDRS) evaluates:• 1. mentation, behavior, and mood; 2. ADLs; 3. motor

examination; 4. complications of therapy; 5. modified Hoehn and Yahr staging; 6. Schwab and England ADL scale

• Planning Determine baselines for patent functioning

• Implementation Identify patient needs Monitor patient functioning


Management of Parkinson’s Management of Parkinson’s DiseaseDisease


Drug Class: Dopamine Drug Class: Dopamine AgonistsAgonists

• Amantadine hydrochloride Originally for viral infection Administered to Asian influenza with

parkinsonism Action

• Exact MOA is unknown• Slows destruction of dopamine• Aid in release of dopamine from its storage site• Reduction in benefit after 2 to 3 months

Gradual discontinuation



• Amantadine hydrochloride – cont’d Uses

• For relief of symptoms associated with Parkinson’s • Treatment of susceptible strains of viral influenza

Therapeutic outcome• Establish balance of dopamine and ACh in basal

ganglia of brain by enhancing delivery of dopamine to brain cells



• Bromocriptine mesylate Actions

• Ergot derivative the stimulates the D2 dopamine receptors in basal ganglia of brain

Uses• Nearly as effective as levodopa• Used alone or in treatment of mild symptoms or in

combination with carbidopa-levodopa to reduce both dose of carbidopa-levodopa and parkinsonian symptoms

Therapeutic outcome• To stimulate dopaminergic neurotransmission to

relieve the rigidity, akinesia, and tremor associated with dopamine deficiency



• Carbidopa Actions

• Carbidopa is an enzyme inhibitor that reduces metabolism of levodopa, allowing a greater portion of administered levodopa to reach the desired receptor sites in basal ganglia

• No effect when used alone• Must be used in combination with levodopa

Uses• To reduce dose of levodopa • With levodopa, carbidopa increases both plasma

levels and plasma half-life of levodopa• Parcopa

Dissolves in mouth to reduce choking



• Carbidopa – cont’d Therapeutic outcomes

• Establish balance of dopamine and ACh in basal ganglia by enhancing delivery of dopamine to brain cells



• Levodopa Actions

• Dopamine when administered orally does not enter the brain

• Levodopa does cross the BBB, and metabolized into dopamine and replaces dopamine deficiency in basal ganglia

• Dopamine stimulates D1, D2, and D3 dopamine receptors

Uses• 75% respond favorably to levodopa, but after a

few years the response diminishes, becomes uneven and more side effects

Therapeutic outcomes• Establish balance of dopamine and ACh in basal ganglia

of brain by enhancing delivery of dopamine to brain cells



• Pergolide mesylate Actions

• Ergot derivative potent to D1, D2, and D3 dopamine receptor stimulant

• Exert its effect in patients with Parkinson’s disease by directly stimulating postsynaptic dopamine receptors in nigrostriatal system of brain

Uses• Used in combination with carbidopa-levodopa • Associated with development of restrictive valvular

heart disease (valvular fibrosis) Therapeutic outcome

• 1. improve motor and ADL scores; 2. decreased “off” time; 3. reduced dosage of levodopa



• Pramipexole Action

• Nonergot dopamine agonist that stimulates D2 and D3 dopamine receptors

Uses• Used alone to manage early S/Sx of parkinsonism

by improving ADLs, tremor, rigidity, bradykinesia, postural stability

• Used in combination with levodopa in advanced parkinsonism to manage similar S/Sx of disease

Therapeutic outcome• 1. improve motor and ADL scores; 2. decreased

“off” time; 3. reduced dosage of levodopa



• Ropinirole Action

• Nonergot dopamine agonist that stimulates D2 and D3 dopamine receptor

Uses• Used alone to manage early S/Sx of parkinsonism

by improving ADLs, tremor, rigidity, bradykinesia, postural stability

• Used in combination with levodopa in advanced parkinsonism to manage similar S/Sx of disease and reduce degree of “on-off” symptoms associated with long-term use of levodopa

Therapeutic outcome• 1. improve motor and ADL scores; 2. decreased

“off” time; 3. reduced dosage of levodopa


Chapter 15Chapter 15

Lesson 15.2Lesson 15.2


Learning ObjectivesLearning Objectives

• Develop a health teaching plan for an individual being treated with levodopa

• Name the action of bromocriptine, carbidopa, levodopa, entacapone, and apomorphine on neurotransmitters involved in Parkinson’s disease



• List symptoms that can be attributed to the cholinergic activity of pharmacologic agents

• Cite the specific symptoms that should show improvement when anticholinergic agents are administered to the patient with Parkinson’s disease


Levodopa TherapyLevodopa Therapy

• Baseline assessment UPDRS Check for history of glaucoma

• Implementation Administer with food

• Side effects Report movements and nightmares

• Drug interactions Numerous


Drug Class: COMT InhibitorDrug Class: COMT Inhibitor• Entacapone

Actions• Reduces destruction of dopamine in peripheral tissues,

allows dopamine to reach brain Uses

• Inhibits dopamine metabolism, resulting in a more constant dopaminergic stimulation in brain

Reduces motor fluctuations, increases on-time, reduces off-time, results in reduction in dosage of L-dopa

• Not effective over time• Report hallucinations• Monitor blood pressure• Interacts with antihypertensive agents

Therapeutic outcome• 1. improve motor and ADL scores; 2. decreased “off” time;

3. reduced dosage of levodopa


Drug Class: Anticholinergic AgentsDrug Class: Anticholinergic Agents

• Mode of action Reduce hyperstimulation caused by excessive

acetylcholine• Indications

Reduce severity of tremor and drooling More useful in patients with minimal symptoms

and no cognitive impairment Little effect on rigidity, bradykinesia, or

postural abnormalities• Therapeutic outcomes

Reduction in severity of tremor and drooling caused by a relative excess of ACh in basal ganglia


Drug Class: Anticholinergic Drug Class: Anticholinergic AgentsAgents

• Drug interactions Amantadine, TCAs, Phenothiazines

• Enhance anticholinergic S/E• Confusion, hallucinations are characteristic of

excessive anticholinergic activity L-dopa

• Large doses of anticholinergic may slow gastric emptying and inhibit absorption of L-dopa

• Side effects Nightmares, depression, confusion,

hallucination, orthostatic hypotension, palpitations, dysrhythmias


Names of Anticholinergic Names of Anticholinergic AgentsAgents

• Benztropine mesylate (Cogentin)• Biperiden hydrochloride (Akineton)• Diphenhydramine hydrochloride (Benadryl)• Orphenadrine citrate (Banflex, Norflex)


Drug Class: Miscellaneous AgentsDrug Class: Miscellaneous Agents

• Selegiline Actions

• Potent monoamine oxidase type B inhibitor• Reduces destruction of dopamine in brain allows

dopamine to reach brain Uses

• Have similar adjunctive activity to carbidopa-levodopa • Combination of selegiline and carbidopa-levodopa

improves memory and motor speed and may increase life expectancy

• Neuroprotective effect by interfering withh ongoing degeneration of striated dopaminergic neuron

• Used in early treatment of PD to slow progression of symptoms and delay initiation of L-dopa therapy

• Not effective over time


Drug Class: Miscellaneous Drug Class: Miscellaneous AgentsAgents

• Selegiline Side effects and drug interactions

• Report hallucinations or confusion• Monitor blood pressure• Tell patient to avoid Chianti, fava beans, and cheese

High tyramine content Lead to hypertensive reaction

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