Integrated Case
November 28, 2002
Drug-Related Problems for Mrs. Smith
• Mrs. Smith is continuing to experience
signs and Sx of Parkinson’s disease for
which she may be receiving too low a dose
of Sinemet and/or require additional therapy
• Mrs. Smith is at risk of developing another
episode of TIA and/or stroke for which she
requires drug therapy
• Mrs. Smith is experiencing Sx of short-term
insomnia for which she may benefit from
therapy
• Depression?
Parkinson’s disease
How does it present?
• Four classical feature:
• 1. Tremor
• 2. Rigidity
• 3. Bradykinesia
• 4. Postural disturbances
• Other Sx…
Mrs. Smith’s disease progression:
Mrs. Smith’s RFs:
Parkinson’s Disease
Mrs. Smith’s disease progression:
• started with unilateral hand tremor and progressed
to both hands
• decreased motor activity or bradykinesia seen as
– difficulty initiating physical activities such as walking,
– difficulty buttoning her clothes, and
– picking up objects
• likely has masked facies and a slow gait
Mrs. Smith’s RFs:
• age, rural area??
Parkinson’s disease
Is Tx needed?
Tx Options:
Levodopa + Carbidopa/benserazide
Selegiline (Deprenyl)
Anticholinergic medications
Amantadine (Symmetrel)
Dopamine agonists
COMT inhibitor -Tolcapone (Tasmar) ; Entacapone
(Comtan)
Mrs. Smith’s management
• She is presently on Sinemet 100/25 tid
• Options for management:
At risk for TIA and/or stroke
• What is TIA?
• RIND: reversible ischemic neurological
deficit
• What is stroke?
• Thrombus vs. embolus
TIA / Stroke
General Risk Factors
HTN, prior TIA/stroke, age, male, smoking, etc.
(consider cardiac RF)
Mrs. Smith’s RF
Is Tx needed?
TIA / Stroke
Tx options - Prophylaxis
• ASA
• Ticlopidine
• Clopidogrel
• Warfarin
• Dipyridamole
• Sulfinpyrazone
• tPA – for acute ischemic stroke (within 3
hours)
TIA / Stroke - Aspirin
•
•
•
•
•
•
efficacy and place in therapy:
Dutch TIA (30mg vs. 300mg ASA), UKTIA
(300mg vs. 1200mg ASA): effective in secondary
prophylaxis at lower doses
Decreases RR by 24% in secondary Px
Dose tried: 30mg daily – 600 mg bid
Side effects: GI upset, PUD
Convenience: daily
cost: cheap
TIA/Stroke
• What would be an appropriate agent for
Mrs. Smith and why?
Mrs. Smith’s sleep problem
• What is insomnia?
• Types of insomnia
Mrs. Smith’s sleep problem
• Drug-induced causes:
• Reason for Mrs. Smith’s insomnia
• Is Tx needed?
Mrs. Smith’s sleep problem
• Tx Options:
–
–
–
–
–
–
–
Non-pharmacological options
benzodiazepines
antihistamines
Zopiclone
zaleplon
chloral hydrate
barbiturates
Non-pharmacological
Strategies
• Good Sleep “Hygiene”
• alcohol use, caffeine, cigarette smoking,
fluids
• chronic insomnia: counselling, behavioural
& biofeedback, sleep deprivation, etc.
Comparison of Benzodiazepines
Drug
t 1/2
diazepam
flurazepam
oxazepam
lorazepam
temazepam
triazolam
onset oxidation active met
Comparison of Benzodiazepines
Drug
t 1/2
onset oxidation active met
Diazepam 2-4ds quick
yes
Flurazepam 2-3ds inter-fast yes
Oxazepam 5-15h slow
no
Lorazepam 10-20h interm no
Temazepam 10-20h slow-inte no
Triazolam 2-5h
quick-int yes
yes
yes
no
no
no
no
Mrs. Smith’s sleep management
Depression
• How is it diagnosed?
• RF
Depression
Typical Signs and Sx:
emotional Sx: no interest in life, social w/d,
worthlessness
physical Sx: fatigue, insomnia/hypersomnia,
loss of wt. & appetite or weight gain
cognitive Sx: difficulty concentrating, poor
memory, indecisiveness
Does Mrs. Smith have depression?
Depression – Goals of Tx
Reduce Sx of acute episode and facilitate pt’s
return to same level of functioning: remission
Acute phase: Tx 6-12 weeks (to relieve Sx)
To prevent relapse: Tx 4-9 mos (continuation
phase)
To prevent recurrence: Tx > 1 year (mtce
phase)
Consider risk of recurrence: after 1 episode: 50%
Depression – general approach to Tx
Antidepressants of equivalent efficacy in
grps of pts. in comparable doses
Initial choice empirically done (consider
pt’s Hx of response, family Hx, depression
subtype, concurrent medical conditions, DI,
ADR, cost)
65-70% of pts will respond to first agent
Non-pharmacological Tx: psychotherapy
(1st line if mild-moderate); combined has
better efficacy
Depression – comparison of agents
SSRI (fluoxetine, fluvoxamine, paroxetine,
sertraline)
Nefazodone
Venlafaxine
Bupropion
TCAs: 1st generation: amitriptyline
2nd generation: desipramine
Moclobemide
MAOI: phenelzine, tranylcypromine
Depression – comparison of agents
Consider MOA
Efficacy equal
Onset of effect
Potential side effects
Potential drug interactions (see CANMAT
guidelines from readings)
Switching between antidepressants (see
guidelines)
Pharmacy Care Plan
• Clinical Outcomes
To control Sx of PD and decrease further
disease progression
To prevent future TIAs and/or stroke
To help Mrs. Smith fall asleep at night and to
feel well rested
• Pharmacotherapeutic Outcome
- appropriate anti-Parkinosonian medication…
- Appropriate anti-platelet agent…
- Ensure that she receives counselling re: good
sleep hygeine…
Pharmacy Care Plan
• Pharmacotherapeutic Endpoints
– Improvement in initiating walking, buttoning
blouse, picking up objects, in 3 days to a week
and optimal in one month
– No TIAs/ stroke while on therapy (confusion,
paresthesias, etc.)
– Able to fall asleep within ½ hour in 3-4 days
Pharmacy Care Plan
• Alternatives & Assessment
Parkinson’s Disease:
TIA/Stroke:
insomnia:
Pharmacy Care Plan
• Therapeutic Plan
Pharmacy Care Plan
• Therapeutic Plan Endpoints
Sinemet: nausea, vomiting, wearing off
effect, on-off effect…
ASA: nausea, no blood in stools (tarry
stools), no PUD
Selegiline: insomnia, jitteriness
DA agonist: nausea, orthostatic hypotension,
insomnia, dyskinesias…
Pharmacy Care Plan
• Monitoring Plan
Work closely with patient, family, caregivers
and health care providers