Pharm 2, Exam 1

Parkinson’s Disease

A neurodegenerative disease that primarily affects the dopamine-producing neurons that results in a progressive loss of dopamine in the CNS

s/s of Parkinson’s

Pill-rolling tremors, muscle rigidity, shuffling gait, bradykinesia, postural instability, “masked face”

Secondary Parkinsonism

Symptoms of parkinson’s that are caused by head trauma, brain infections, brain tumors, exposure to neurotoxins, antipsychotic drugs

Dopamine

Plays a role in reward and return, motor contro, motivaiton, interest, activities, and passes messages through the brain

High Levels of Dopamine

Can contribute to positive symptoms of schizophrenia or psychosis, gambling, addiction, poor impulse control

Low Levels of Dopamine

Less motivation or excitement about thigns, depression, fatigue, restless, anxiety; ADHD, parkinson’s disease

Dopamine inhibits the release of which chemical messenger?

Acetylcholine

When dopamine is low, which chemcial messenger level is high?

Acetylcholine levels are high

Acetylcholine

Plays a role in brain functions, such as memory, and body functions, such as muscle contractions

High levels of Acetylcholine can lead to…

Parkinson’s disease & Cholinergic crisis

Low levels of Acetycholine can lead to…

Alzheimer’s disease and Myasthenia Gravis

Dopamine Agonist Medications

Pramipexole, Bromocriptine, Ropinirole, Apomorphine

Dopamine agonist medications are mostly for…

Rescue medication for “off times”

Mechanism of action for dopamine agonists

Activiate dopamine receptors

Why is bromocriptine administered less frequently for off times of parkinson’s?

Due to the risk of valvular heart disease

Which dopamine agonist is administered less frequently due to the risk of valvular heart disease?

Bromocriptine

Dopamine Agonist Complications

Sudden inability to stay awake, day time sleepiness, orthostatic hypotension, psychosis, impulse control disorder, dyskinesias, nausea

Patient education for dopamine agonists

Avoid activities that require alertness, notify provider immediately if there is a sudden inability to stay awake

Dopamine Synthesis Medications

Cabidopa/Levodopa (Sinemet)

Mechanism of action for Levodopa in Carbidopa/Levodopa

Crosses the BBB, because dopamine alone cannot cross the barrier

“Wearing off” effect of carbidopa/levodopa

When the beneficial effects of the medication fade away before the next scheduled dose is due, causing Parkinson's symptoms to return

“On-off” Phenomena of carbidopa/levodopa

Where a patient's response to levodopa unpredictably alternates between mobility ("on" periods) and severe immobility or symptom return ("off" periods)

Complications of Carbidopa/Levodopa

Nausea, vomitting, drowsiness, dyskinesias, orthostatic hypotension, cardiovasular effects, psychosis, discoloration of bodily fluids, activation of malignant melanoma

What color may Carbidopa/Levodopa turn sweat and urine?

Red, brown, black

Patients on Carbidopa/Levodopa should avoid foods high in what?

Pyridoxine

Foods high in pyridoxine

Wheat germ, green veggies, bananas, whole grain ceral, liver legumes

True or False: A patient should aburptly stop carvidopa/levodopa?

False

Catecholamine-O-Methyltransferase (COMT) Inhibitors Medicaitons

Entacoapone, Tolcapone

Mechanisms of action of COMT Inhibitors

Enhance the effect of levodopa by blocking its breakdown

Unique adverse effect of Tolcapone

Liver Failure

Entacapone

Urine discoloration

Complications of COMT Inhibitors

GI upset, discoloration of urine to yellow-orange, rhabdomyolysis, liver failure

True or False: A patient can abruptly stop taking Entacapone and Tolcapone?

False

Monoamine Oxidase-B (MAO-B) Inhibitor medications

Selegiline and Rasagiline

Mechanism of action of MAO-B Inhibitors

Prevent dopamine breakdown

Why do we use Selegiline

Can preserve dopamine produced from levodopa and prolong the effects of levodopa but only up to 1 or 2 years

Why do we use Rasagiline

Preserves dopamine in the brain and is not converted into amphetamine or methamphetamine like selegiline does

Selegiline and Rasagiline can lead to what?

Hypertensive crisis

What time of day should patients take Rasagiline and Selegiline?

No later than noon

Complications of Rasagiline and Selegiline?

Insomnia, HTN Crisis, Nausea, diarrhea

Patients should avoid foods high in what when taking Rasagiline and Selegiline?

Foods high in tyramine~ charcutrie boards

Dopamine Releaser Medication

Amantadine

Mechanism of action of Dopamine Releaser medications

Prevents dopamine reuptake

Complications of Amantadine

CNS effects, dry mouth, blurred vision, dilated pupils, urinary hesitancy or retention, constipation, discoloration of the skin

Patient education with Amantadine

Chew sugarless gum for dry mouth, discoloration of th eskin will subside when the medicaiton is discontinued

Centrally Acting Anticholinergic medications

Benztropine and Trihexyphenidyl

Indication of use for Benztropine and Trihexphenidyl

Rescue drug for muscular rigidity

Complications of Centrally Acting Anticholinergics

Nausea, Vomiting, Dry mouth, Blurred vision, mydriasis, urinary hesitancy or retention, constipation, sedation, drowsiness

Neuropathy

Peripheral nerve damage, which manifests as pain, tingling, and weakness, primarily in the extremities

Neuropathy causes damage to what?

Nerves in the periphery that transmit information from the brain and spinal cord to the rest of the body

Antiepileptic Medications

Pregabalin (lyrica), Carbamazepine (Tegretol)

Mechanism of action for Pregabalin

Modulates calcium channel activity in the CNS, reducing the release of neurotransmitters such as glutamate, substance P, and noradrenaline involved in pain transmission

Indications of use for Antiepileptics

Neuropathic Pain

Complications of Antiepileptics

Dizziness, drowsiness, dry mouth, blurred vision, weight gain, suicidal thoughts, respiratory depression, SJS

What are expected complications of Antiepileptics

Dizziness, Drowsiness, Dry mouth

What must a patient avoid when taking an Antiepileptics

Alcohol

Mechanism of action of Carbamazepine

Inhibits sodium channels, stabilizing hyperactive neuronal membranes and reducing repetitive neuronal firing

Indication of use for Carbamazepine

Trigeminal neuronalgia, seizures

What should a patient avoid when taking carbamazepine?

Grapefruit juice

Antidepressant Medications

Duloxetine and Amitriptyline

Mechanism of action for duloxetine

Block reuptake of norepinephrine as well as serotonin in effects similar to SSRIs

Indications for use for Duloxetine

Diabetic peripheral neuropathic pain, fibromyalgia, major depressive disorder, anxiety

Patient education regarding duloxetine

Report sexual dysfunction to the provider, do not abrupty stop medicaiton, avoid alcohol

Complications of Duloxetine

Neuroleptic Malignant syndrome, serotonin syndrome

Mechanism of action of Amitriptyline

Block reuptake of norepinephrine and serotonin in the synaptic space, thereby intensifying the effects of these neurotransmitters

Indications of use for Amitriptyline

Fibromyalgia, anxiety, depression, neuropathic pain

Complications for Amitriptyline

Anticholinergic effects, sedation, toxicity

Major Neurocognitive Disorder

A disorder that negatively affects the client’s ability to think and act

What is the most common Major Neurocognitive Disorder?

Alzheimer’s Disease

What do Major Neurocognitive Disorders lead to?

Diminished neural and cognitive abilities that often progressively worsen with time

Alzheimer’s Disease

A condition that results in brain atrophy, especially in the cortext of the brain, where beta amyloid plaques can be deposited, forming tangles of proteins and neurons that ultimately degenerate the brain cells

Frontotemporal Demntia

Develops when tau proteins aggregate in unexpected quantities due to genetic mutations, with deposits in the frontal and temporal lobes eventually causing MND. The effects of frontotemporal dementia include changes in personality, speaking ability, and behavior

Huntington’s Disease

A genetic mutation that can be passed from parents to children. This mutation leads to the production of an unexpected huntingtin protein, which accumulates in neurons and disrupts their function, causing neurodegeneration and cognitive impairment as well as other characteristic manifestations of this disease

NMDA Antagonist medication

Memantine

NMDA Antagonist method of action

Decrease glutomate so neurons don’t break down

True or False: Memantine slows the progression of Alzheimer’s but does not cure it?

True

Complications of Memantine

Dizziness, fatigue, headache, diarrhea, weight gain, urinary frequency, hypertension, rash, anemia

The nurse should question Memantine in which patient?

Patient with renal impairment

What substance should you never give Memantine with?

Sodium Bicarbonate

Why should Memantine and Sodium Bicarbonate not be combined?

Decreases excretion and increases blood toxicity levels

Monocolonal Antibodies Medication

Lecanemab (Leqembi)

Mechanism of action of lecanemab

Directed against aggregrated soluble and insoluble forms of beta amyloid to reduce amyloid-beta plaques

Complications of Lecanemab

Brain edema, cerebral hemorrhage, seizures, diarrhea, A fib, lymphocytopenia

What patient should a nurse question giving Lecanemab to?

Patients with a history of brain microhemorrhages or hemorrhages

Cholinesterase Inhibitor Medications

Donepezil, Galantamine, Rivastigmine

Method of action of Cholinesterase inhibitor medications

Break down acetylcholine

What are the main complications of cholinesterase inhibitor medications?

Cholinergic Crisis and Excessive muscarinic stimulation

What is the antidote for a cholinergic crisis due to a cholinesterase inhibitor medication?

Atrophine

Cholinergic Crisis

Salivation, Lacrimination, urination, diaphoresis, diarrhea, GI cramping, Emesis, Bradycardia, Bronchospasm

Excessive muscarinic stimulation

Increase GI motility, increased GI secreations, Diaphoresis, increased salivation, bradycardia, urinary urgency

When should donepezil be taken?

At bedtime

ADHD

Poor attention span, behavior control issues, and hyperactivity

s/s of ADHD

Easy distractiblity, failure to receive or follow instructions, inablity to focus on one task at a time, difficulty remembering, frequent misplacement, excessive talking or interrupting others

Norepinephrine

Plays major role in attention, alertness, and executive function, which is why many ADHD medications are designed to increase norepinephrine activity in the brain

High levels of norepinephrine

Anxiety, jitteriness or feeling “wired”

Low levels of norepinephrine

It’s hard to focus, ignore distractions, stay organized, or finish tasks

Dopamine-Norepinephrine Reuptake inhibitors medications

Bupropion (Wellbutrin)

Mechanism of Action of Bupropion

Increases the levels of norepinephrine and dopamine in the CNS by blocking thier reuptake into the presynaptic nerve

Patient education regarding Bupropion

Report rashes, do not abruptly stop medication

Black box warning of bupropion

Suicidal ideation