SCRIBBLE PAD

Drugs used to treat

Parkinson’s
Levodopa Therapy
• Levodopa is a precursor of
dopamine
• Levodopa is taken up by the
dopaminergic terminal, converted
into dopamine, and then released as
needed
Drug Therapy for PD
• Aimed at increasing levels of
dopamine as long as there are
functioning nerve terminals
remaining
• Antagonizes or blocks the effects of
ACh
– Slows the progression of the disease
Drug Therapy for PD (cont’d)
• Indirect-acting dopamine-receptor
agonists
– MAOB inhibitors: selegiline,
rasagiline
– COMT inhibitors: entacapone,
tolcapone
– Presynaptic dopamine release
enhancer: amantadine
Drug Therapy for PD
• Anticholinergic drugs
– Benztropine, others
• Antihistamines
– Diphenhydramine
• Nondopamine-receptor agonists
– Ergot: bromocriptine
– Nonergot: pramipexole, ropinirole,
apomorphine
• Dopamine replacement drugs
– Carbidopa, carbidopa-levodopa
Selective MAOI Therapy: Selegiline
• MAOIs break down catecholamines in the
CNS, primarily in the brain
• Selegiline [Eldepryl] is a selective MAO-B
inhibitor
– Causes an increase in levels of dopaminergic
stimulation in the CNS
– Selegiline is a newer, potent, irreversible MAOI
that selectively inhibits MAOB
– Does not elicit the “cheese effect” of the
nonselective MAOIs used to treat depression (if
10 mg or less is used)
Selective MAOI Therapy: Selegiline
• Used in combination with levodopa or
levodopa-carbidopa
• Used as an adjunct when a patient’s response
to levodopa is fluctuating
• Allows the dose of levodopa to be decreased
– Delays development of unresponsiveness to
levodopa therapy
Selective MAOI Therapy: Selegiline
• Adverse effects are usually mild
– Nausea, lightheadedness, dizziness,
abdominal pain, insomnia, confusion,
dry mouth
– Doses higher than 10 mg/day may
cause more severe adverse effects,
such as hypertensive crisis
Direct-Acting Dopamine Receptor
Agonists
• Nondopamine dopamine receptor agonists
(NDDRAs)
– Ergot derivatives (bromocriptine and pergolide)
– Nonergot drugs (pramipexole, ropinirole,
apomorphine)
• Dopamine replacement drugs
– Levodopa, carbidopa, carbidopa-levodopa
(Sinemet)
Direct-Acting Dopamine Receptor
Agonists
• Nondopamine dopamine receptor agonists
(NDDRAs)
– Ropinirole
• Newer, nonergot NDDRA
• Used for PD and restless leg syndrome
– Apomorphine
• Newer, nonergot dopamine agonist
• Subcutaneous injection
Dopamine Replacement Drugs
• Replacement drugs (presynaptic)
– Work presynaptically to increase brain levels of
dopamine
– Levodopa is able to cross the blood-brain barrier,
and then it is converted to dopamine
– However, large doses of levodopa needed to get
dopamine to the brain also cause adverse effects
Dopamine Replacement Drugs
• Replacement drugs
– Carbidopa is given with levodopa
– Carbidopa does not cross the blood-brain
barrier and prevents levodopa breakdown
in the periphery
• As a result, more levodopa crosses the
blood-brain barrier, where it can be
converted to dopamine
Anticholinergic Therapy
• Anticholinergics block the effects of
Ach
• Antidyskinetic properties
• Used to treat muscle tremors and
muscle rigidity associated with PD
– These two symptoms are caused by
excessive cholinergic activity
• Does not relieve bradykinesia
(extremely slow movements)
Anticholinergic Therapy
• ACh accumulates because of the imbalance of
dopamine
– As a result, overstimulation of the
cholinergic excitatory pathways occurs
• Muscle tremors and muscle rigidity
• Cogwheel rigidity
• Pill-rolling movement of fingers and
head bobbing while at rest
Anticholinergic Therapy
• benztropine mesylate
– Also used to treat extrapyramidal symptoms caused
by use of antipsychotic drugs
• Trihexyphenidyl (generic only)
• Antihistamines also have anticholinergic
properties
– diphenhydramine
Anticholinergic Therapy:
Indications
• Used in the treatment of PD to cause smooth
muscle to relax, resulting in reduced muscle
rigidity and akinesia
• Also used to treat drug-induced
extrapyramidal reactions to certain
antipsychotic drugs
Anticholinergic Therapy:
Adverse Effects
• Drowsiness, confusion, disorientation
• Constipation, nausea, vomiting
• Urinary retention, pain on urination
• Blurred vision, dilated pupils, photophobia,
dry skin
• Decreased salivation, dry mouth
Nursing Implications
• Perform a thorough assessment, nursing
history, and medication history
• Include questions about the patient’s:
– CNS
– GI and GU tracts
– Psychologic and emotional status
Nursing Implications
• Assess for signs and symptoms of PD
– Masklike expression
– Speech problems
– Dysphagia
– Rigidity of arms, legs, and neck
• Assess for conditions that may be
contraindications
Nursing Implications
• Administer drugs as directed by
manufacturer
• Provide patient education regarding PD
and the medication therapy
• Inform patient not to take other
medications with PD drugs unless he or
she checks with physician
Nursing Implications
• When starting dopaminergic drugs, assist
patient with walking because dizziness
may occur
• Administer oral doses to minimize GI
upset
• Encourage patient to force fluids to at
least 2000 mL/day (unless
contraindicated)
• Taking levodopa with MAOIs may result in
hypertensive crisis
Nursing Implications
• Patient should be taught not to
discontinue antiparkinsonian drugs
suddenly
• Teach patient about what therapeutic
and adverse effects to expect with
antiparkinsonian drug therapy
Nursing Implications
• Levodopa preparations may darken
the patient’s urine and sweat
• Therapeutic effects of COMT
inhibitors may be noticed within a
few days; it may take weeks with
other drugs
Nursing Implications (cont’d)
• Monitor for response to drug therapy
– Improved sense of well-being and
mental status
– Increased appetite
– Increased ability to perform ADLs,
to concentrate, and to think clearly
– Less intense parkinsonian
manifestations, such as less tremor,
shuffling gait, muscle rigidity, and
involuntary movements