antiparkinsonian drugs ppts 1
TRANSCRIPT
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ANTIPARKINSONIAN ANTIPARKINSONIAN DRUGSDRUGSDR. NUTANBALA GOSWAMI,ASSOCIATE PROFESSOR,PHARMACOLOGY DEPARTMENT,GOVT. MEDICAL COLLEGE, BHAVNAGAR.
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PARKINSONISM
• A degenerative and progressive disorder• Associated with neurological consequences
of decreased dopamine levels produced by the basal ganglia (substantia nigra)
• Extrapyramidal motor function disorder symptoms characterized by
1. Rigidity2. Tremor3. Hypokinesia/Bradykinesia4. Impairment of postural balance - falling
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PARKINSONISM - RIGIDITY
Increased resistance to passive motion when limbs are moved through their range of motion – normal motions “Cogwheel rigidity” – Jerky quality – intermittent
catches of movement Caused by sustained involuntary contraction of
one or more muscles Muscle soreness; feeling tired & achy Slowness of movement due to inhibition of
alternating muscle group contraction & relaxation in opposing muscle groups
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PARKINSONISM – CONTD.• Tremor
– First sign – Affects handwriting – trailing off at ends of words– More prominent at rest – Aggravated by emotional stress or increased
concentration– “Pill rolling” – rotary motion of thumb and forefinger– NOT essential tremor – intentional
• Bradykinesia: Loss of automatic movements:– Blinking of eyes, swinging of arms while walking,
swallowing of saliva, self-expression with facial and hand movements, lack of spontaneous activity, lack of postural adjustment
– Results in: stooped posture, masked face, drooling of saliva, shuffling gait (festination); difficulty initiating movement
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PD – IMPAIRMENT OF POSTURAL BALANCE
Prone to falling
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PARKINSONISM (PD) - SIGNS
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PARKINSONISM - HISTORY• Parkinson's disease was first formally
described in "An Essay on the Shaking Palsy," published in 1817 by a London physician named James Parkinson, but it has probably existed for many thousands of years. Its symptoms and potential therapies were mentioned in the Ayurveda, the system of medicine practiced in India as early as 5000 BC, and in the first Chinese medical text, Nei Jing, which appeared 2500 years ago
• Majority of causes are Idiopathic
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PARKINSON`S DISEASE - PATHOPHYSIOLOGY
The Basal Ganglia Consists of Five Large Subcortical Nuclei that Participate in Control of Movement: Caudate Nucleus Putamen Globus Pallidus Subthalamic Nucleus Substantia Nigra
Striatum – Caudate Nucleus and Putamen Substancia nigra pars compacta provide DA
innervation to striatum
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PD, PATHOPHYSIOLOGY – CONTD. Degeneration of
neurones in the substantia nigra pars compacta
Degeneration of nigrostriatal (dopaminergic) tract
Results in deficiency of Dopamine in Striatum - >80%
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PD, PATHOPHYSIOLOGY – CONTD. Disruption of balance between Acetylcholine and
Dopamine:
Striatum
Substancia Nigra
DA fibres (Nigrostrital pathway) GABAergic fibres
Cholinergic
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PD, PATHOPHYSIOLOGY – CONTD.
Imbalance primarily between the excitatory neurotransmitter Acetylcholine and inhibitory neurotransmitter Dopamine in the Basal Ganglia
ACh
DA
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PARKINSONISM - ETIOLOGY Genetic: Environmental triggers:
Infectious agents – Encephalitis lethargica (epidemic) Environmental toxins - MPTP (1-methyl-4-phenyl-1,2,3,6-
tetrahydropyridine) Acquired Brain Injury
Excitotoxicity Glutamate, the normal excitatory transmitter in neurones
in excess Mediated by activated NMDA receptor Ca++ overload – destructive processes
Energy metabolism and aging: Reduction in function of complex 1 of mitochondrial-
electron transport chain Oxidative stress: Free radicals (`OH) – hydrogen peroxide
and oxyradicals : damage to lipid membranes and DNA
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PARKINSONISM - ETIOLOGY
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TREATMENT OF PD
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CLASSIFICATION OF ANTIPARKINSONIAN DRUGS1. Drugs acting on dopaminergic system:
a) Dopamine precursors – Levodopa (l-dopa)b) Peripheral decarboxylase inhibitors –
carbidopa and benserazidec) Dopaminergic agonists: Bromocriptyne,
Ropinirole and Pramipexoled) MAO-B inhibitors – Selegiline, Rasagilinee) COMT inhibitors – Entacapone, Tolcaponef) Dopamine facilitator - Amantadine
2. Drugs acting on cholinergic systema) Central anticholinergics – Teihexyphenidyl
(Benzhexol), Procyclidine, Biperidenb) Antihistaminics – Orphenadrine, Promethazine
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CNS ANTIPARKINSONIAN DRUGS
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ANTIPARKINSONIAN DRUGS
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CNS ANTIPARKINSONIAN DRUGS
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QUESTION ?
• Dopamine and Tyrosine Are Not Used for Parkinson Disease Therapy, Why?
– Dopamine Doesn't Cross the Blood Brain Barrier
– Huge amount of tyrosine decreases activity of rate limiting enzyme Tyrosine Hydroxylase
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LEVODOPA
• Single most effective agent in PD• Inactive by itself but immediate precursor of
Dopamine• Peripherally - 95% is decarboxylated in
peripheral tissues in gut and liver to dopamine– This dopamine acts on peripheral organs like
heart, blood vessels and CTZ etc. (NOT CNS)• 1 - 2% crosses BBB, taken up by neurons and
DA is formed– Stored and released as neurotransmitter
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ACTIONS OF LEVODOPA – CNS
• Effective in Eliminating Most of the Symptoms of Parkinson Disease (initially motor)– Bradykinesia and Rigidity Respond Quickly – Reduction in Tremor Effect with Continued therapy
• Secondary symptoms - Handwritting , speech, facial expression and interest in life improves gradually
• L -Dopa less Effective in Eliminating Postural Instability and Shuffling Gait Meaning Other Neurotransmitters are Involved in Parkinson Disease
• Behavioural Effects:– Partially Changes Mood by elevating mood, and increases
Patient sense of well being - General alerting response– Disproportionate increase in sexual activity– No improvement in dementia – psychiatric symptoms
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ACTIONS OF LEVODOPA – CONTD.• CVS:
– Cardiac Stimulation Due to Beta adrenergic effect on Heart
– Though stimulates peripheral adrenergic receptor – no rise in BP
– Orthostatic Hypotension - some individuals – central DA and NA action
– In elderly cardiovascular problems - transient tachycardia, cardiac arrhythmias and hypertension
– Tolerance to CVS action develops within few weeks• CTZ: DA receptors cause stimulation – nausea
and vomiting – tolerance• Endocrine: Decrease in Prolactin level and
increase in GH release
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LEVODOPA - PHARMACOKINETICS• Absorbed rapidly from small intestine – aromatic
amino acid transport system• High First Pass Effect
– Competition for amino acids present in food competes for the carrier
– Also depends on gastric emptying and pH• Peak plasma conc. 1-2 hrs and half life - 1 to 3 Hrs• Metabolized in liver and peripherally - secreted in
urine unchanged or conjugated with glucoronyl sulfate
• Central entry into CNS (1%) - mediated by membrane transporter for aromatic amino acids – competition with dietary protein
• In CNS – Decarboxylated and DA is formed – therapeutic effectiveness
• Transport back by presynaptic uptake or metabolized by MAO and COMT
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LEVODOPA - PHARMACOKINETICS3 – OMD
COMT
Levodopa
DDC
DopamineAny drug which can reduce DDC peripherally (called peripheral decaroxylase inhibitors) - Would be beneficial and cause higher bioavailability, longer half-life, better availability in CNS and also reduce the daily dose of levodopa
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LEVODOPA - ADRS• Initial Therapy:
Nausea and vomiting - 80% of patients Postural hypotension , but asymptomatic : 30 %
of patients tolerance develops – disappear after prolonged treatment
Cardiac arrhythmias (due to beta adrenergic action and peripheral CA synthesis) - tachycardia, ventricular extrasystoles and, rarely, atrial fibrillation
Exacerbation of angina
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LEVODOPA (ADVERSE EFFECTS) - PROLONGED THERAPY1. Abnormal movements: Facial tics,
grimacing, tongue thrusting, choreoathetoid movements of limb after few months of treatment
2. Behavioural effects:– 20 to 25% of Population– Trouble in Thinking (Cognitive Effects)– L- dopa can induce: Anxiety, psychosis,
confusion, hallucination, delusion– Hypomania - Inappropriate Sexual Behavior;
"Dirty Old Man", "Flashers“ - Drug Holiday (1 - 3 weeks)
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LEVODOPA (ADVERSE EFFECTS) - PROLONGED THERAPY – CONTD. Fluctuation in Motor Performance:
Initial therapy – each dose - good duration of action 9more than half-life) Suggesting Nigrostriatum retains capacity to store and
release Prolonged therapy – “buffering” capacity is lost –
each dose causes fluctuation of motor state - each dose has short duration of action– short therapeutic effect (1 – 2 Hrs) – bradykinesia and rigidity comes back quickly - "On-off" Phenomenon Like a Light Switch: Without Warning
DYSKINESIA – excessive abnormal involuntary movements even in on phase (more troublesome)
Dyskinesia often with high plasma conc. of levodopa Dyskinesia = Bradykinesia and Rigidity in terms of
patient comfortness
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LEVODOPA (ADVERSE EFFECTS) - PROLONGED THERAPY – CONTD. Denervation Supersensitivity:
In Basal Ganglia – destruction of Dopaminergic Neurons –increase in Dopamine Receptors postsynaptically
L Dopa Therapy - increase Dopamine at synaptic Cleft - but too many Receptors - Denervation Supersensitivity
Effect - Increased Postsynaptic Transmission
Initial disappearance of Parkinson Syndrome
Onset of Dyskinesia
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LEVODOPA – DRUG INTERACTIONS Pyridoxine – abolishes therapeutic effect of levodopa Antipsychotic Drugs – Phenothiazines, butyrophenone block the action of levodopa by blocking DA receptors. Antidopeminergic – domperidone abolishes nausea and vomiting Reserpine – blocks levodopa action by blocking vesicular uptake Anticholinergics – synergistic action but delayed gastric emptying – reduced effect of levodopa Nonspecific MAO Inhibitors – Prevents degradation of peripherally synthesized DA – hypertensive crisis by the tyramine-cheese effect (tyramine is found in cheese, coffee, beer, pickles and chocolate), when given to a person taking a MAO Inhibitor - tyramine is not broken down - tremendous release of Norepinephrine)
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LEVODOPA VS PERIPHERAL DECARBOXYLASE INHIBITORS
Carbidopa and Benserazide: In practice, almost always administeredDo not penetrate BBBDo not inhibit conversion of l-dopa to DA in
brainCo-administration of Carbidopa - will
decrease metabolism of l-dopa in GI Tract and peripheral tissues - increase l-dopa conc in CNS - meaning decrease l-dopa dose and also control of dose of l-dopa
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LEVODOPA VS PERIPHERAL DECARBOXYLASE INHIBITORS – CONTD. Benefits:
Plasma t1/2 – prolongedDose of levodopa – 30% reductionReduction in systemic complicationsNausea and Vomiting – lessCardiac – minimum complicationsPyridoxine reversal of levodopa – do not
occurOn/Off effect – minimumBetter overall improvement of patient
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LEVODOPA – CARBIDOPA (MORE LEVODOPA AVAILABILITY IN CNS )
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CNS ANTIPARKINSONIAN DRUGS
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CNS -- ANTIPARKINSONIAN DRUGS PATIENT EDUCATION
“Wearing off” phenomenon – gradual worsening of symptoms as medication begins to lose effectiveness, despite maximal doses “Drug Holiday” when levodopa no longer working effectively
(usually 10-day period of hospitalization) Community resources to assist patient and family Safety Effect on blood pressure –
Hypotension Hypertensive crisis of MAOI accidentally taken
“Sleep attacks” – newer dopamine agonists (pramipexole & ropinirole)
GI: Constipation – high fiber, high roughage, increased fluids
GU: urine color changes – brownish-orange (entacapone)
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CNS -- ANTIPARKINSONIAN DRUGSNURSING PROCESS
Nursing Actions
Exact timing of medication – cannot be administered late
Oral doses given with food Avoid foods in Vit B6 – reverse effects of levodopa Force fluids >2,000 mL/day High roughage, high fiber diet
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• Five Stages
– Flexion of affected arm - tremor / leaning toward unaffected side
– Slow shuffling gate– Increased difficulty walking – looks for
support to prevent falls– Further progression of weakness – assistance
with ambulation– Profound disability – may be confined to
wheelchair
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THANK YOU