Parkinsons_p4.pdf

RxPREP 2 022 CO U RS E BOOK DRUG DOSING I Rx PREP ©2021 , ©2022 SAFETY/SIDE EFFECTS/MONITORING Dopamine agonist injection for advanced disease: a "rescue" movement drug for "off" periods. Apomorphine /Apokyn, Kynmobi) Injection, sublingual film Taken in addition to other PD medications Inject...

RxPREP 2 022 CO U RS E BOOK DRUG DOSING I Rx PREP ©2021 , ©2022 SAFETY/SIDE EFFECTS/MONITORING Dopamine agonist injection for advanced disease: a "rescue" movement drug for "off" periods. Apomorphine /Apokyn, Kynmobi) Injection, sublingual film Taken in addition to other PD medications Injection: CONTRAINDICATION Start with 0.2 ml (2 mg) SC PRN (up to 5x/day); titrate by 1 mg every few days Do not use w ith 5HT·3 antagonists (e.g., ondansetron) due to severe hypotension and loss of consciousness Max single dose: 0.6 ml (6mg) Lasts 45-90 minutes Must be started with a test dose in a medical office SIDE EFFECTS Severe nausea/vomiting, hypotension, yawning, dyskinesias, somnolence, dizziness, QT prolongation Sublingual film: dry mouth, tongue pain NOTES Monitor supine and standing blood pressure Subllngual film: 10-30 mg PRN; max of 5 doses/day For emesis prevention: give trimethobenzamide (Tigan) 300 mg PO TID, or a similar antiemetic, started 3 days prior to the initial dose I Carbidopa/Levodopa (Sinemet) Drug Interactions Contraindicated with non-selective MAO inhibitors (a two-week separation is required). Iron and protein-rich foods can J. absorption. Do not use with dopamine blockers, which will worsen Parkinson symptoms (e.g., phenothiazines, metoclopramide). OTHER DRUGS FOR PARKINSON DISEASE DRUG DOSING SAFETY/SIDE EFFECTS/MONITORING Amantadine: blocks dopamine reuptake into presynaptic neurons and increases dopamine release from presynaptic fibers. Primarily used to treat dyskinesias associated with peak-dose of carbidopa/levodopa. Amantadine IR: 100 mg PO BID IR: tablet, capsule, syrup Osmolex ER: 137 mg PO daily, increase after 1 week to 274 mg daily Amantadine extendedrelease (Gocovri, OsmolexER) Gocovri: 129 mg daily, increase weekly to max dose of 322 mg daily -1. dose in renal impairment eGFR < 15 ml/min/1.73 m2 : ER products contraindicated WARNINGS Somnolence (including falling asleep without warning during activities of daily living), compulsive behaviors, psychosi~ (hallucinations, delusions, paranoia) SIDE EFFECTS Dizziness, orthostatic hypotension, syncope, insomnia, abnormal dreams, dry mouth, constipation Cutaneous reaction called livedo reticularis (reddish skin mottling - can require drug discontinuation) NOTES Gocovri is indicated for the treatment of dyskinesia in patients receiving levodopa-based therapy Selective MAO-B inhibitors: block the breakdown of dopamine which increases dopaminergic activity. Primarily used as adjunctive treatment to carbidopa/levodopa; rasagiline has an indication for monotherapy. Selegiline (Zelapar) Capsule, tablet: 5 mg PO BID, CONTRAINDICATIONS Capsule, tablet (generics) with breakfast and lunch Use in combination with other MAO inhibitors (Including linezolld), opiolds, SNRls, TCAs, others (see Drug Interactions) Zelapar- ODT Emsam - patch; only indicated for depression ODT: 1.25-2.5 mg daily (not recommended if CrCI < 30 ml/ min) Selegiline can be activating; do not take dose at bedtime; if dosed twice daily, take the 2nd dose at mid-day Rasagiline /Azilect) 0,5-1 mg PO daily Safinamide /Xadago) Start with 50 mg once daily; after 2 weeks may increase to 100 mg once daily Xadago : severe hepatic impairment WARNINGS Serotonin syndrome, hypertension, nausea, CNS depression, dyskinesias, impulse control disorders, caution in patients with psychotic disorders (may exacerbate) or ophthalmic disorders /Xadaga) Rasagiline (monotherapy): headache, joint pain, indigestion _ _ _ _ _ ___, MONITORING Adjunctive treatment to carbidopa/levodopa in patients experiencing "off" episodes When stopping treatment: decrease the dose to 50 mg for one week before discontinuing BP, signs of serotonin syndrome, visual changes /Xadago) NOTES May need to reduce levodopa dose when beginning treatment with a selective MAO-B inhibitor 887