TOSCE - PD Meds

A 65 year old gentleman presents to his GP with a 12 month history of tremor in his
hands. His wife comments that he seems to have slowed up over the past year. He is an
ex-smoker and was diagnosed with COAD 8 years ago, the symptoms of which have
been well controlled on a combivent inhaler bd since it was diagnosed. He is taking no
other medications. His father was diagnosed with a movement disorder in his 60s. On
examination he has a symmetrical pill rolling tremor affecting his hands. His gait is
slowed.

List 4 differential diagnoses:

Idiopathic Parkinsons Disease
Benign Essential Tremor
Medication-induced tremor
Lewy Body Dementia
Corticobasal Degeneration
Multi-Systems Atrophy
Progressive Supranuclear Palsy
Frontotemporal Dementia

How would you manage this condition?

Multi Disciplinary Team Management-education, support, nutrition, exercise
Pharmacologic Therapy-given the effect of the tremor on his profession
MOAI (Selegiline, Rasagiline), Dopamine Agonist (bromocriptine, pergolide),
Amantidine, Anticholinergic ( biperidin, procyclidine)

Could consider delaying L Dopa treatment until later in disease process (not very
effective for treatment of tremor. Associated with significant SEs (motor fluctuations,
dystonias, dyskinesias)

Over the following 4 years his symptoms progressively worsen. His tremor is now so
significant that he can no longer write legibly. He has developed significant rigidity
and has difficulty with walking as a result of his rigidity and tremor.

A.What medication should be considered at this time?

B.What advice should you give him when prescribing this medication?

C.Write a prescription for this gentleman.

A. Levodopa (must be given in combination with cabergoline to prevent metabolism to

dopamine prior to crossing BB-can cause hypotension and nausea).
B. Take with meals to prevent nausea.
Beware Side Effects: nausea, vomiting, confusion, hallucinations, light headedness
(hypotension), headache.
Later in course of disease: motor disturbances (motor fluctuations, dyskinesia, dystonia)
DDS (Dopamine Dysregulation Syndrome)-hypomania/mania
Compulsive Behaviour

C. Sinemet: immediate release (until correct dose established) 25/100mg tab bd po.
Titrate over several week to 25/100mg tds if required. Can give up to 1g levodopa.

2 years later he begins to experience sudden off periods, whereby he becomes

extremely bradykinetic and rigid and has difficulty moving again.
How would you treat these episodes?

COMT Inhibitors-prolong effects of L Dopa (increases T by reducing methylation of L

Dopa)
Dopamine agonists.
Extended release L Dopa (Madopar)-may not be effective at reduceing motor
fluctuations.