Pharm Session 7:

Alzheimers, Parkinsons, and Migraines

There are some drug interactions that should be noted with the triptans and the MAO inhibitors, also the first questions were asked in class and here are the answers.

Happy studying!

-Peter

    1. What is the medical term for the visual aura before a migraine.
      1. scotoma
  • Why can’t a 60 year old female with HTN continue to take her triptan for migraines?
    1. HTN
  1. In alzheimer’s Dx what neurotransmitter is decreased up to 90%?
    1. acetylcholine
  2. AD pt needs more drug teaching if?
    1. will i stop losing memory with the drug?- 
      1. the meds only slow deterioration

Headaches and Migraines

    • have triggers
    • not migranes
    • types
      • Tension
        • squeezing sensation
      • sinus
        • in the sinuses
      • cluster
        • pain terrible and is usually on one side
      • Migraine
        • no known cause for migraine and cluster
        • throbbing, debilitating pain
        • one sided 60% of the time
        • can have an “aura” before the migraine but not everyone
        • triggers can be from flashing lights, loud noises, or changes in pressures
          • menstrual cycles (in the middle of the cycle)
          • Foods
          • physical activities
        • Patho
          • trigeminal nerve depol
        • scotoma – is the aura
        • meds should be taken asap to have best results
  • DO NOT GIVE opiates to releave pain
          • ½ life of opiates is shorter than the migraine
            • rebound pain is extreme!
        • OTC meds are most effective
          • excedrin migraine
            • .25g acetaminophen, .25g aspirin and 65mg caffeine, nothing special
            • basic and effective
        • Ergot Alkaloid
          • Ergotamine
            • for migraines, Alpha blocker
            • S/E: HTN, MI trigger
              • increased risk of stillborn pregnancy increased uterine stim, and decreases the blood flow to the placenta
              • seperate 24hrs between the use of ergotamine and sumatriptan.
            • related to ACID
        • Serotonergic Drugs
          • Triptans
            • sumatriptan and zolmitriptan
              • stim 5 – HT in the brain
              • it vasoconstricts and inhibits inflammation
              • not for prophylaxis of migraines
              • S/E: stroke, MI, cerebral hemorrhage
  • don’t take within 24 hours of ergotamine
                • toxicity w/ other 5-ht blockers, prozac,paxil, zoloft
  • wait 2 weeks to use a MAO-I med
      • Reglan is great to help migraines and is an antiemetic
      • prevention
        • Beta blockers
        • Anti seizure
          • valproic acid, and topiramate
            • prevent gen depol of the cortex

Parkinson’s Disease

there needs to be a balance of neurotransmitters to prevent this

    • too little dopamine and too much acetylcholine
    • focus on improving gait, bradykinesia, and ADL
      • tremor and rigidity is not how they measure when to change doses
    • no real cures
    • Meds: Dopaminergic and anticholinergic agents
      • dopamine is the most common
        • Levodopa (Dopar)
      • anticholinergic
        • Benztropine (Cogentin)
    • Issues:
      • unpredictable in GI absorption and BBB crossing
        • changing # of sensitive receptors
    • MAO-B inhibitors are used in patients with mild symptoms
      • Selegiline and rasagiline
      • when the symptoms are increased, given meds change to levodopa and Dopamine agonist
      • S/E: drooling, constipation
    • Levodopa
      • best effect in the first two years
      • take time off the drug “holiday”
      • many d/d interactions
  • vitamin B6 allows less levodopa to get to the CNS
    • Carbidopa
      • no bad effects on its own
      • increase usable levels of levodopa in the CNS
        • Is the CAR that drives levodopa to the CNS
    • levodopa/carbidopa/entacapone can come in one pill
    • Pramipexole (Mirapex)
      • dopamine agonist
      • S/E: sexy grandpa/grandma
    • MAOI
      • 2 kinds
        • MAOA helps metabolize norepinephrine and serotonin
        • MAOB metabolizes dopamine
      • food interactions: aged cheeses and meats, yeast, bread, BEER
      • Selegiline (Eldepryl)
  • stop antidepressants 2-7 weeks befor using
  • Anticholinergic
    • Benzotropine (Cogentin) and trihexyphenidyl (Artane)
      • similar to atropine, antimuscarinic

Alzheimers

connection to chromosome 21 (and Down’s tri21)

statins may be helpful to slow onset and progression

research is looking at decreasing the “tangles”

  • disorganized web formation that is seen upon autopsy in the patient’s brain
    • thought of like a road block for neural impulses

Risk factors

  • Low education
  • smoking
  • physical inactivity
  • depression
  • HTN
  • DM
  • risk slightly reduced by
    • brain training, mediterranean diet and low ETOH
    • Not effective: gingko and Vit E

meds focus on increasing ACH levels, but are not very effective

  • all for early dementia, late dementia is not benifited by these drugs and the side effects are too much.

Acetylcholinesterase inhibitors

  • donepezil (Aricept)
    • stop ACHesterase, increasing ACH
    • treatment of early dementia

Cholinesterase inhibitors

  • works in 1:12 patients
  • S/E: diarrhea, Headache, dreams, bronchoconstriction
    • bradycardia and AV block
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