CLINICAL PHARMACOLOGY BSN 210

Week 3:
Drug Therapy for Parkinson’s and Alzheimer’s Diseases
Drug Therapy for Osteoporosis and Muscle Relaxation

Academic Year 2020-2021

Sem. 2

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 Intended learning outcomes

At the end of this week the student should be able to:

• List the names, actions, possible side effects, and adverse effects of drugs for
osteoporosis, muscle relaxant, Parkinson’s and Alzheimer’s diseases.

• Describe what to teach patients about drugs for osteoporosis, muscle relaxant,
Parkinson’s and Alzheimer’s diseases.

• Explain what to do before and after giving drugs for osteoporosis, muscle
relaxant, Parkinson’s and Alzheimer’s diseases.

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 Alzheimer's Disease

• Progressive and incurable condition that destroys brain

cells.

• Gradual loss of intellectual abilities such as memory and

extreme changes in personality and behavior. (for example,
thinking, remembering, and reasoning).

• It is the most feared and common form of dementia.

• About 10% of people over age 65 are affected, and as

many as 50% of people over age 85.

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 Alzheimer's Disease/
Pathophysiology
• Presence of large amounts of the protein beta-amyloid
(Abeta), which clumps together and forms plaques between
cells in the brain.

• Other proteins twist and form tangles within the neurons.

• Decrease level of acetylcholine in the brain that carry

messages between nerve cells.

• As a result, neurons die in the areas of the brain that are

important to memory and other essential mental abilities
(language).
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 Alzheimer's Disease/
Pathophysiology

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 Alzheimer's Disease/
Symptoms

Early Stage Middle Stage Late Stage

• Forgetfulness • Difficulty speaking, • Aggressiveness
understanding,
• Difficulty recalling • Anxiety
reading, and
events and activities
writing. • Need for total
• Difficulty remembering care
• Failure to recognize
names of familiar
familiar people and • Wandering away
people and things
places. from home
• Inability to solve simple
• Forgetting how to
mathematics problems
perform simple
tasks such as
brushing teeth and
combing hair.
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 Types of Drugs for
Alzheimer's Disease

Cholinesterase/Acetylcholinesterase Inhibitors:
Donepezil, Rivastigmine, and Galantamine
• Can temporarily slow the progression of symptoms in some
patients.

• Reduce the activity of the enzyme acetylcholinesterase that

breaks down acetylcholine in the synapses of neurons.

• This action keeps levels of acetylcholine higher.

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 Alzheimer's Disease

Adverse effects:
• Abnormal heart rhythms
such as bradycardia and
atrial fibrillation.

• Gastrointestinal (GI)
bleeding

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 What To Do Before/After Giving
Drugs for Alzheimer's Disease

• Obtain a complete list of drugs currently being used by the

patient.

• Assess the patient for baseline cognitive function (memory,

attention, reasoning, language, and ability to perform
simple tasks).

• Obtain a baseline weight & blood pressure and heart rate

and rhythm.

• Assess a patient's ability to swallow before giving drugs

because he or she may be at risk for aspiration.
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 What To Do Before/After Giving
Drugs for Alzheimer's Disease

• Ask about a history of liver or kidney problems.

• Assess for signs of low hemoglobin or hematocrit.

• Because acetylcholinesterase inhibitors may cause GI

bleeding, monitor the patient carefully for any signs of
bleeding.

• Give drugs with food to minimize the GI upset that is

common with these drugs.

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 What To Do Before/After Giving
Drugs for Alzheimer's Disease

• Do not crush time released pills or open time-released

capsules.
• Administer Donepezil at bedtime.
• Rivastigmine should be used cautiously for
patients with asthma or chronic obstructive
pulmonary disease (COPD) because it
increases cholinergic activity

• Teach care providers to remind patients to use

the bathroom every 2 hours to avoid
incontinence episodes while taking drugs for
Alzheimer's disease.

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 Parkinson's disease

• A slow, progressive, degenerative disease of the nervous system.

Pathophysiology:
• A decrease in the production of dopamine in the basal ganglia of the
brain.

• As a result, the basal ganglia is less able to produce smooth

movements.

• These changes cause symptoms of increased tremor, lack of

coordination, and slowed or reduced movements (bradykinesia).

• Parkinson's disease begins subtly and progresses gradually.

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 Parkinson's disease

• Risk factors:
• Age, especially age 50 and older.
• Genetic and environmental toxin factors.
• Some medications as antihypertensive (Reserpine)

The four major symptoms of Parkinson's disease are:

• Tremor at rest
• Rigidity
• Bradykinesia (slow movements and difficulty starting to
move)
• Abnormal gait

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 Parkinson's disease

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 Types of Drugs for Parkinson's
Disease

Drug classes for Parkinson's disease are:

1. Dopaminergic/dopamine agonists:
Carbidopa-levodopa/ Apomorphine (Apokyn): increase the
amount of dopamine in brain
2. COMT inhibitors:
Entacapone: increase the amount of dopamine in brain
3. Monoamine oxidase B (MAO-B) inhibitors:
Rasagiline: Inhibit the enzyme that breaks down dopamine
4. Anticholinergic drugs:
Benztropine: Block cholinergic nerve impulses.

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 Types of Drugs for Parkinson's
Disease

Intended Responses
• Signs and symptoms of Parkinson's disease are decreased
• Tremor and rigidity of Parkinson's disease are relieved.

Side Effects.
• Dizziness, nausea, and hypotension.

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 Types of Drugs for Parkinson's
Disease

Adverse Effects
• Carbidopa-levodopa:
• Depression with suicidal tendencies
• Neutropenia (decreased number of white blood cells).

• Apomorphine (Apokyn):
• Life-threatening central nervous system (CNS)
depression.
• Respiratory depression, coma, and cardiac arrest.

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 What To Do Before/After Giving
Drugs for Parkinson's Disease

• Drug history
• V/S
• Baseline neurologic and mental status.
• Check for baseline dyskinesia, rigidity,
tremors, and gait.
• Assess swallowing ability.
• Assess if there is pregnancy.

• Assess any kidney or liver disease.

• Drugs must be swallowed whole and
not chewed or split in half.

Dyskinesia is uncontrolled, involuntary movement that may occur with long-

term levodopa use and longer time with Parkinson's.

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 What To Do Before/After Giving
Drugs for Parkinson's Disease

• Be sure to give Apomorphine (Apokyn) subcutaneously and

not intravenously. because intravenous drugs are
immediately absorbed and act very rapidly.

• Reassess the patient's mental status and watch for

confusion or hallucinations.

• To determine the effectiveness of drug therapy for

Parkinson's disease, regularly reassess the patient for
dyskinesia, rigidity, tremors, and gait.

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 What To Teach Patients Taking
Drugs for Parkinson's Disease

• Patients should be taught to notify their prescriber

immediately if symptoms of Parkinson's disease (for
example, shaking, stiffness, and slow movement) become
worse.

• Report any changes in swallowing ability to the prescriber

because of the increased risk of aspiration.

• While taking Rasagiline, patients should avoid foods that

contain tyramine (Aged cheeses, Avocados, Bananas, Fish,
Liver).
• Tyramine (TIE-ruh-meen) is an amino acid that helps regulate blood pressure.

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 Osteoporosis

• The process of old bone cell removal is known as

osteoclastic activity.

• Osteoclastic activity also causes bones to lose minerals,

especially calcium, a process known as bone resorption of
calcium.
• Replacement with new bone cells is known as osteoblastic
activity.

• Osteoclastic activity reduces bone density and strength

whereas osteoblastic activity improves bone density and
strength.

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 Osteoporosis

• When osteoclastic activity exceeds osteoblastic activity,

bone mineral loss also reduces bone density.

• The problem of imbalanced bone metabolism is known as

osteoporosis.

• All older people have some degree of osteoporosis as a

result of normal aging.

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 Osteoporosis

Health problems associated

with osteoporosis:
• Increased risk for bone
fractures.
• Posture changes

• The person loses height

as the spine bends
forward, outward, or
inward.

• These changes can limit

lung expansion and lead
to pulmonary problems.

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 Types of Drugs to Manage
or Slow Osteoporosis

1. Nutritional supplements (calcium and vitamin

D)
2. Bisphosphonates
3. Estrogen agonists: work by changing hormone levels in the
body

4. Osteoclastic monoclonal antibodies.

Intended Responses
• Bones maintain density and strength.
• Blood calcium levels remain normal.
• Bone fractures do not occur.

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 Types of Drugs to Manage
or Slow Osteoporosis

Nutritional supplements (calcium and activated

vitamin D)
• Bone density and strength depend on an adequate supply
of the mineral calcium.

• Calcium in the diet is absorbed in the small intestine in the

presence of activated vitamin D.

• Anyone at risk for developing osteoporosis or who has

osteoporosis is recommended to supplement the diet with
additional calcium and vitamin D.

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 Types of Drugs to Manage
or Slow Osteoporosis

Bisphosphonates
1. Alendronate (Fosamax)
2. Ibandronate (Boniva)

• Type of calcium-modifying drug that both prevents bones

from losing calcium and increases bone density.

• Both work by moving blood calcium into the bone, binding

to calcium in the bone, and preventing osteoclasts from
destroying bone cells and resorbing calcium.

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 Types of Drugs to Manage
or Slow Osteoporosis

Bisphosphonates
• Alendronate (Fosamax)
• Ibandronate (Boniva)
• Side effects: abdominal pain,
headache, esophageal reflux, &
nausea.
• The most serious adverse effect:
Jawbone necrosis (osteonecrosis).
• Teach patients to take the drug early
in the morning, right after breakfast,
and to drink a full glass of water.
Jawbone necrosis

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 Types of Drugs to Manage
or Slow Osteoporosis

Bisphosphonates
• Alendronate (Fosamax)
• Ibandronate (Boniva)
• To prevent esophageal reflux and irritation, teach patients
to remain in the upright position (sitting, standing, or
walking) for at least 30 minutes after taking an oral
bisphosphonate.

• Stress to patients the need to inform their dentists about

his/her drugs before any tooth extraction or invasive dental
procedure involving the jawbone.

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 Types of Drugs to Manage
or Slow Osteoporosis

Estrogen agonists
Estrogen/bazedoxifene
• Osteoporosis developed and progressed more rapidly after
menopause, when a woman's estrogen production was
very low.

• Estrogen has a protective influence in preventing bone

density loss.

• Estrogen reduces calcium resorption and increased bone

density.

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 Types of Drugs to Manage
or Slow Osteoporosis

Estrogen agonists
Estrogen/bazedoxifene
• Estrogen problems include: breast and uterine tumors,
blood clots, and uterine bleeding.

• Side effects: muscle spasms, nausea, and indigestion.

• Adverse effects: Increased risk for thrombotic events,

which include deep vein thrombosis, stroke, myocardial
infarction, and pulmonary embolism.

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 Types of Drugs to Manage
or Slow Osteoporosis

Osteoclastic monoclonal antibodies:

Denosumab

• Antibodies directed against immature osteoclasts.

• Prevents osteoclasts maturation and reduces their actions

of reducing bone density and strength.

• Side effects: skin rashes and musculoskeletal pain.

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 Types of Drugs to Manage
or Slow Osteoporosis

Osteoclastic monoclonal antibodies:

Denosumab

• The most serious adverse effect: Jawbone necrosis

(osteonecrosis), severe allergic reactions and possible
anaphylaxis.

• Assess for an allergic reaction during and after SC injection

of denosumab. Keep emergency equipment in the room
with the patient.

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 Muscle Spasm

• A skeletal muscle spasm is the involuntary contraction of a

single muscle, group of related muscles, or just a part of a
muscle.

• This most often occurs when a nerve or nerves controlling

contraction to that muscle depolarizes spontaneously and
inappropriately.

• Common causes of inappropriate nerve depolarization

include pressure on the nerve, swelling along the nerve
path, and electrolyte imbalances, especially low blood
calcium and magnesium levels.

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 Muscle Spasm

• Spasms can also occur when a muscle is irritated or

damaged.

• When a large muscle has a spasm, rather than just an

isolated twitch, intense pain from a lack of oxygen getting
to the muscle can result.

• Muscle function is reduced during spasms and twitches.

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 Skeletal muscle relaxants

• Drugs that act by depressing the central nervous system

(CNS).

• This reduces motor nerve depolarization and results in a

reduction of skeletal muscle spasms.

• Also this increases mobility of affected skeletal muscles.

• They are used for pain and insomnia when excessive

skeletal muscle contractions or spasms contribute to these
problems.

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 Skeletal muscle relaxants

The three classes of skeletal muscle relaxants

are:
• Carbamates (methocarbamol)
• Cyclobenzaprines
• Benzodiazepines (Diazepam)

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 Skeletal muscle relaxants

Intended Responses
• Skeletal muscle relaxation
• Reduced muscle spasms
• Sedation
• Pain relief
• Increased mobility of affected muscles
Side Effects.
• The most common side effects of the carbamates are
flushing, hypotension, bradycardia, and fainting.
• The most common side effects of cyclobenzaprine are
dizziness, headache, and dry mouth, and urinary retention.

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 Skeletal muscle
relaxants
Adverse Effects.
• The most common adverse effects of the carbamates are
amnesia, and angioedema.
• angioedema is an area of swelling of the lower layer of skin and tissue just
under the skin or mucous membranes.

• The drug should be used cautiously, if at all, in patients who

have a seizure disorder because it can lower the seizure
threshold.

• When methocarbamol is given intravenously and infiltration or

extravasation (leakage of fluid into the tissues) occurs, pain,
phlebitis, and sloughing at the injection site may occur.
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 Skeletal muscle relaxants

Adverse Effects.
• The most common adverse effects of cyclobenzaprine are
cardiac dysrhythmias and prolonged cardiac conduction.

• This drug is not to be used in a patient who is recovering

from a myocardial infarction or Dysrhythmia.

• Cyclobenzaprine also lowers the seizure threshold and

should never be used for patients who have a seizure
disorder.

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 What To Do Before/After Giving
Skeletal Muscle Relaxants

• The carbamates and cyclobenzaprine should not be given to anyone

who has a seizure disorder because these drugs lower the seizure
threshold

• Assess the level of consciousness, cognition, and skeletal muscle

reactivity.

• Ask whether he or she has a seizure disorder.

• Before giving the first dose of cyclobenzaprine, assess the patient's
blood pressure and radial and apical pulses for any skipped beats,
extra beats, or any other type of irregular heart beat.

• If you find any persistent heart beat irregularity, notify the prescriber
before administering the drug.

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 What To Do Before/After Giving
Skeletal Muscle Relaxants

• Patients may become very drowsy and are at risk for falling.
• Raise the side rails and remind them to call for help to get out of bed
for any reason.

• Muscle relaxants can cause a sudden lowering of blood pressure,

especially when the patient changes position (orthostatic hypotension).
• Help the patient change position slowly. When getting out of bed, he or
she should sit for a few minutes on the side of the bed before
attempting to get up.

• Help him or her during walking to prevent falling.

• When administering an intravenous dose of a carbamate, assess for
pain, redness, swelling, or a cord-like feel over the vein that indicate an
infiltration or extravasation.

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 What To Teach Patients Taking
Skeletal Muscle Relaxants

• Remind patients that these drugs are to be taken only on a short-term

basis. Usually the drugs are prescribed for 2 to 3 weeks because of
their potential for abuse.

• Just like for any drug that causes sedation, warn patients to avoid
operating any dangerous equipment, driving a car, or making critical
decisions while under the influence of these drugs.

• Remind the patient to avoid alcohol because the sedation effect of

these drugs is potentiated by alcohol.

• Because cyclobenzaprine increases sun sensitivity and can lead to

severe sunburn, remind patients to use sunscreen, hats, and protective
clothing during sun exposure.

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 Drugs list for Top 10 Drugs

Name of the Drug Classification

Donepezil Acetylcholinesterase Inhibitors (Drug for
Alzheimer's Disease)
Rivastigmine Acetylcholinesterase Inhibitors (Drug for
Alzheimer's Disease)
Galantamine Acetylcholinesterase Inhibitors (Drug for
Alzheimer's Disease)
Carbidopa-levodopa Dopamine agonist (Drug for Parkinson's disease)

Apomorphine Dopamine agonist (Drug for Parkinson's disease)

Benztropine Anticholinergic drugs (Drug for Parkinson's disease)

Alendronate Bisphosphonates (Drug for Osteoporosis)

Estrogen (Drug for Osteoporosis)
methocarbamol Carbamates muscle relaxant
Diazepam Benzodiazepines muscle relaxant

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 References

• Workman, M., LaCharity, L., and Kruchko, S. (2015)

Understanding Pharmacology: Essential for Medication Safety.
Saunders Elsevier

• Lehne, R, A. (2010) Pharmacology for Nursing Care, 8th Edition,

Saunders Elsevier, Canada

• https://www.google.com/search?
q=Muscle+Spasm&rlz=1C1CAFA_enAE615AE615&source=lnms
&tbm=isch&sa=X&ved=2ahUKEwibgIi-rbbsAhWq8uAKHduaD-
0Q_AUoAXoECBgQAw&biw=1366&bih=625

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