Chapter 24

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24
PHARMACY PREP

PARKINSONS DISEASE

Next 1 Questions refer to the following case
1) A 65-year-old male patient has Parkinsons disease taking levodopa and carbidopa.
Doctor gives him bromocriptine. What is correct procedure? Patient medical history
includes dyskinesia.
I-Give bromocriptine and stop levodopa
II- Give test dose of bromocriptine
III- Start bromocriptine with low dose and decrease dose of levodopa
A. I only
B. III only
C. I and II only
D. II and III only
E. All of the above
Ans-B

2-When levodopa and carbidopa immediate release is switched to a sustained-release
formulation
I. The medication should be upheld for 8 hours
II. The dose interval should be increased
III. The dose of levodopa should be reduced by 50%
a) I only
b) III only
c) I and II only
d) II and III only
e) All of the above
Ans: C

3-A patient using pergolide must be advised by the physician to report any of the
following s/e, EXCEPT:
a) Abdominal pain
b) Dry cough
c) Visual hallucinations
d) Orthostatic hypotension
E-Cardiac valve regurgitation
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Ans: A

4- Side effects of levodopa except
A. Hallucination
B. Depression
C. Nystagmus- movement of eye
D. Confusion
E. Nausea and vomiting
Ans-
Tips: Nystagmus is a side effect of phenytoin

5- we add carbidopa to levodopa to/for:
I-Decrease nausea and vomiting
II-Bradykinesia
III-CNS side effect
A. I only
B. III only
C. I and II only
D. II and III only
E. All of the above
Ans-

6- In case of switching sinemet to sinemet CR
I-Decrease dose by 50%
II-Increase dose by 30-50%
III-Dont give Sinemet 8 hours before initiation of sinemet CR
A. I only
B. III only
C. I and II only
D. II and III only
E. All of the above
Ans-
Tips: Standard dose (IR) is 1:10 and 20:200
For (CR) 1:40 and 2.5:100
If the dose is exceeding 750mg per day switch 1:4 to 1:10

7-If switching from Levodopa to Levodopa/Carbidopa:
I-Reduce levodopa to 20%
II-Dont give levodopa 12 hours before initiation of levodopa/carbidopa
III- Increase dose by 30-50%
A. I only
B. III only
C. I and II only
D. II and III only
E. All of the above
Ans-C

8- A patient being treated effectively for Parkinsons disease with levodopa asks you to
recommend a good multivitamin product. What should you say?
I-Multivitamin products containing pyridoxine may significantly interact with the
levodopa treatment, eliminating all the therapeutic benefits of the treatment.
II-Multivitamin products containing pyridoxine may significantly improve the levodopa
treatment, should be monitored cautiously
III- Multivitamin products containing pyridoxine are essential supplement in levodopa
and carbidopa therapy.
A. I only
B. III only
C. I and II only
D. II and III only
E. All of the above
Ans-a

9- A patient with Parkinsons, monitor all EXCEPT:
A. Sleep disturbance
B. Know if unilateral or bilateral
C. Hypotension
D. Tardive dyskinesia
Ans-C

10- How should a levodopa prescription be taken with regard to meals?
I. Taking the medication with food reduces side effects
II. Taking medication with food reduces absorption
III. Taking with food increases absorption
A. I only
B. III only
C. I and II only
D. II and III only
E. All of the above
Ans-A

Next 3 Questions refer to the following case.
J D is a 72-year-old male who has been experiencing increased rigidity during the early
afternoon. He has had PD for 2 years. He has been keeping a diary of his on and off
times at home, and shows it to you today. His medical history, in addition to PD, includes
type 2 diabetes mellitus, prostate cancer, and depression.
Current medications are:
Levodopa/carbidopa 100/25 qid
Gliclazide 80 mg bid
Flutamide 250 mg tid
Sertraline 25 mg od

11- which of the following could explain his increased rigidity?
a) Gastroparesis, a secondary symptom of PD, leading to decreased absorption of
levodopa
b) A drug-drug interaction between levodopa/carbidopa and sertraline
c) Peak dose dyskinesia occurring after the noon dose of levodopa/carbidopa
d) Too high a dose of levodopa/carbidopa
Ans-A

12- Which is not a potential solution to his problem?
a) Discontinue levodopa/carbidopa
b) Add a dopamine agonist
c) Adjust the timing of levodopa/carbidopa doses
d) Use long-acting levodopa/carbidopa
Ans-A

13- J D arrives with a prescription for controlled release levodopa-carbidopa 200/50 bid
the following week. What should you discuss with the physician?
a) The fact that short-acting levodopa/carbidopa should be used 5 times per day before
switching to long-acting levodopa/carbidopa
b) The fact that controlled release levodopa/carbidopa has lower bioavailability than
short-acting levodopa/carbidopa, and thus, the levodopa/carbidopa dose should be
30% higher
c) The possibility of adding an anticholinergic medication in the future to help with J Ds
rigidity
d) The drug interaction between levodopa/carbidopa and gliclazide
Ans-

14- Which of the following medications has a significant interaction with selegiline?
a) Bromocriptine
b) Donepezil
c) Meperidine
d) Naproxen
Ans-C

FV is a 69-year-old gentleman who presents with right sided tremor of the hand,
cogwheel rigidity, visual disturbances, and drooling. His physician diagnosed PD.

15- Which of the following FVs symptoms is specific to PD?
a) Cogwheel rigidity
b) Drooling
c) Unilateral tremor
d) Visual disturbances
e) None of the above
Ans-C

16- FVs symptoms do not affect his work or activities of daily living. His physician
decides to start levodopa/carbidopa CR 200/50 once daily. Which of the following is true
regarding initiation of levodopa therapy?
a) Starting therapy with levodopa will ensure that motor fluctuations do not occur
later in the course of the disease
b) Clinical guidelines (the treatment pathway) suggest that levodopa therapy
should be started only when symptoms becomes disabling or cause significant
functional impairment, to delay the development of motor fluctuations. The
patient must be informed and actively involved in the decision of when to
initiate therapy.
c) Motor fluctuations occur more commonly when therapy is initiated with slow-
release levodopa/carbidopa
d) If started early enough, levodopa therapy can slow the progression of PD.
Ans-B

17- When FV starts to experience fluctuations in his response to the levodopa therapy, his
physician recommends discussing dietary changes with dietitian. Which dietary
intervention will be most helpful for FV?
a) Decrease the number of calories to avoid weight gain due to immobility
b) Increase protein intake because levodopa is protein bound
c) Modify timing of protein intake to avoid reduced levodopa absorption
d) Change to a liquid diet to reduce risk of aspiration pneumonia related to dysphagia
Ans-C

AG is a 77-year-old female who has had difficulty sleeping over the past several days and
some leg cramping and rigidity in the early hours of the morning.
Her medical history includes: PD, Angina and Seborrhea
Current medications are:
levodopa/carbidopa 100/25, 1 tablet at 0800, 1200, 1600, prn at 2000
Amantadine 100 mg od
ASA-EC 325 mg od
NitroDur 0.6 mg qam
Valisone scalp lotion hs
Nitroglycerin 0.3 mg prn x3 q5min for angina

18-Which of the following is the most likely explanation for AGs symptoms?
a) Anticholinergic effects of amantadine
b) On-off motor fluctuation
c) Wearing off effect
d) Festination
Ans-C

19- which of the following would you suggests improving AGs symptoms?
a) Switch to controlled release levodopa/carbidopa 200/50 tid
b) Switch to controlled reels levodopa/carbidopa 200/50 bid
c) Discontinue levodopa/carbidopa and start selegiline 2.5 mg bid, as it can benefit
insomnia
d) Decrease each dose of levodopa/carbidopa to tablet
Ans-A

20- What is the likelihood that AG will experience hallucinations at some time during her
therapy with levodopa/carbidopa?
a) This highly unlikely
b) 80%; this occurs in most patients because levodopa/carbidopa increases dopamine
levels
c) Up to 20%
d) 50%
Ans-C

DP is an 85-year-old male resident of a long-term care facility. He has been experiencing
increased periods of rigidity and bradykinesia throughout the day, as well as dyskinesias
manifested by facial grimacing and lip smacking. He often freezes when he arises in the
morning. Most days, he has alternating periods of immobility and fluid movement
associated with dyskinesias. His antiparkinsonian medication seems to work for about 3
hours, after which time he becomes rigid and movement is slow. This fluctuation is
making it difficult for DP to carry out his activities of daily living, including eating. DP
has had PD for about 5 years, and has depression, anxiety, and a history of UTIs. DP
does not a history of psychosis, and he is not currently experiencing signs and symptoms
of psychosis. He is taking levodopa/carbidopa 250/25 1 tablet qid, sertraline 50 mg od,
loxapine 5 mg hs, and cotrimoxazole 1 tablet bid for a UTI. His MMSE score was 21/30.

21- Which of DPs medications is mot likely to have a negative impact on the control of
DPs PD?
a) Cotrimoxazole
b) Levodopa/carbidopa
c) Loxapine
d) Sertraline
Ans-C

22- Which intervention would be most helpful for DP?
a) Add amantadine to the regimen
c) Add clozapine
d) Discontinue levodopa
Ans-B

23- What is a possible explanation for DPs response fluctuations?
a) Altered dopaminergic receptor sensitivity
b) Increased rate of gastric emptying
c) Lack of protein in his diet
d) All of the above
Ans-A

24- DP is switched to controlled release levodopa/carbidopa 200/50, 2 tablets tid. He
appears to have less fluctuation in on and off times after a few weeks of therapy. He
has, however, started to have paranoid ideations, and has experienced hallucinations.
What is the best strategy to deal with this problem?
a) Increase levodopa/carbidopa dose
c) Add risperidone
d) Add quetiapine
Ans-D

LX is a 66-year-old female who visits your pharmacy. She arrives at your pharmacy to
refill her prescriptions. She is currently taking levodopa/carbidopa 100/25 five times
daily, bromocriptine 5 mg qid, and selegiline 5 mg q 12 h. LX tells you that she has been
well, except for some difficulty sleeping.

25. What should you recommend to LX?
a) Ensure that selegiline is taken early in the day
b) Ensure that the last dose of levodopa is taken to no later than 6 pm
c) Suggest that you could recommend that her physician switch from bromocriptine to
ropinirole
d) Ensure that she avoids foods with high tyramine content, such as red wine and
smoked meats.
Ans-A

26. LX turns one month later with a new complaint. She tells you that she has noticed
that she is often light-headed when she arises from sitting or lying down. What might be
causing this problem for LX?
a) Progression of PD
b) Levodopa therapy
c) Bromocriptine therapy
d) All of the above
Ans-D

27. Which of the following is a reasonable strategy for dealing with LXs problem?
a) The use of a salt substitute
b) Fluid restriction
c) Fludrocortisone therapy
d) All of the above
Ans-A

Next 8Questions refer to the following case
GZ is a 74-year-old female. She lives with her husband, who has recently had difficulty
dealing with her increased confusion and recent onset of paranoia. Over the past two
weeks, her husband states she has choked on her medications and food several times.

28. GZ is taking benztropine 2 mg tid and bromocriptine 5 mg qid for PD, which she has
had for the past year. Which of the following is true regarding her therapy and symptom
of choking.
a) Benztropine therapy can exacerbate confusion, and should be avoided in patients over
70 years of age
b) Bromocriptine is a better choice to treat PD than levodopa, particularly when
psychotic symptoms appear.
c) Bromocriptine can cause dysphagia and thus the symptom of choking
d) Progression of PD can cause dysphagia, so she should continue to receive benztropine
instead of levodopa therapy to alleviate this symptom.
Ans-A

29. In general, what are some strategies to deal with dysphagia that occurs with PD?
a) Eating during off times
b) Cutting up food into small pieces
c) Decreasing levodopa doses
d) All of the above
Ans-B

30. GZs physician starts levodopa/carbidopa 200/50 tid. The following week, GZs
husband says she wakes up at night screaming; he feels that she is having nightmares.
How can we deal with this problem?
a) Give GZ a hypnotic prior to bedtime
b) Discontinue levodopa/carbidopa, and maintain dopamine agonist therapy
c) Start an antipsychotic, such as olanzapine
d) Decrease the bedtime dose of levodopa/carbidopa to 100/25

J J is a 55-year-old male with diabetes who has had PD for just over 15 months. He has
been on levodopa/carbidopa 100/25 qid and has improved significantly with respect to
rigidity, bradykinesia, and posture. His tremor, however, still has a significant impact on
his work. He is also taking gliclazide 80 mg bid, fludrocorticosine 0.1 mg od, and
levothyroxine 0.05 mg od.

31. Which of the following could be beneficial for treatment of his tremor?
a) Bromocriptine
b) Amantadine
c) Selegiline
d) Pergolide
Ans-B

32. Which of the following is true regarding tremor of PD?
a) Tremor is absent in about 25% of patients with PD
b) Tremor occurs primarily during activity, and diminishes at rest
c) Tremor is the only cardinal sign of PD that is specific to this disease
d) Tremor only occurs in the hands and feet
Ans-A

HV is a 69-year-old female with established PD who is on the following medications:
levodopa/carbidopa 100/25 tid, and tablet at noon; bromocriptine 2.5 mg qid; and
diltiazem CD 120 mg daily for hypertension.

33. HV has recently been experiencing significant dyskinesias. Which of the following is
true?
a) Ergot-derived dopamine agonists, such as bromocriptine, have greater affinity for D2
rather than D1 dopaminergic receptors, and can more often cause dyskinesias
b) Ergot-derived dopamine agonists, such as pergolide, are less likely to cause
dyskinesias
c) HV should be switched from bromocriptine to ropinirole to minimize the incidence of
dyskinesias
d) Pramipexole is the only dopamine agonist that does not cause dyskinesias
Ans-C

34. Which of the following is true of the dopamine agonists?
a) Pramipexole dosage must be modified in renal impairment
b) Bromocriptine has been associated with patients suddenly falling asleep
c) Ropinirole is the longest-acting dopamine agonist, and is thus recommended to be
used at bedtime to alleviate early morning stiffness
d) Bromocriptine is least likely to cause orthostatic hypotension
Ans-D

LE is a 59-year-old male who is taking levodopa/benserazide 100/25 qid. He has taken
this medication at this dose for 3 months and has had little rigidity and posture.

35. Which of the following is true?
a) Levodopa/carbidopa is more effective than levodopa/benserazide, so LE should be
switched to levodopa/carbidopa
b) Benserazide is administered with levodopa for the purpose of reducing the adverse
effects of levodopa and decreasing levodopa
c) The lack of response to this agent means that LE does not have PD
d) None of the above
Ans-B

36. Which of the following is not a consequence of autonomic dysfunction in PD?
a) Urinary incontinence
b) Excessive sweating
c) Sleep disturbances
d) Sexual dysfunction
Ans-C

37. Which of the following statements is true about therapies for PD?
a) Levodopa slows the progression of disease
b) Benztropine is the most effective agent for rigidity
c) Pramipexole dose must be modified in renal impairment
d) Amantadine can cause pulmonary fibrosis
Ans-B

38. Which of the following is true of the COMT inhibitors?
a) They can extend the duration of effect of a dose of levodopa, and decrease off time
b) They can increase breakdown of levodopa in the brain and the periphery
c) They can be useful for initial monotherapy of PD
d) They can cause severe constipation
e) Entracapone should NOT be taken with sinemet at same time.
Ans-A

39- On-off effect seen with anti-parkinsonism drugs treatment can be managed by
I-Adding a second drug to the therapy regimen to correct the effect
II-Reducing the dose of one drug and adding a second drug may be useful
III-Replacing or switching the drug causing the on-off effect with another, which does
not cause the effect.
A. I only
B. III only
C. I and II only
D. II and III only
E. All of the above
Ans-C

40. A 55 years old patient having Parkinsons disease associated with functional
impairment. Best therapy for his doctor to manage that condition is:
(A) L-dopa
(B) Sinemet CR
(C) Sinemet IR
(D) Amantadine
(E) Bromocriptine
Answer: (E)
Reference: Therapeutic Choices 5th edition Page 252

41. A 75 years old patient taking L-dopa and has associated motor symptoms like
moderate dyskinesia. Best thing to do by his doctor:
I Add Amantadine
II Decrease L-dopa and add dopamine agonist
III Stop L-dopa
(A) I only
(B) III only
(C) I and II
(D) II and III
(E) All of the above
Answer: C
Reference: Therapeutic Choices 5th edition Page 252

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