Be Concise And Argue Your Answer With A Paragraph For Each

Be Concise And Argument Your Answer With a Paragraph For Each Answer1

1. A patient with Parkinson’s disease experiencing tremors between doses of levodopa and carbidopa suggests possible motor fluctuations such as "wearing-off." An effective strategy is to add entacapone, a COMT inhibitor, which prolongs the effect of levodopa and reduces fluctuations. Increasing the dose of levodopa may worsen dyskinesias without adequately controlling the fluctuations, while discontinuing carbidopa is not advisable as it reduces levodopa breakdown peripherally and enhances central availability. Amantadine could be beneficial for dyskinesias but is less effective for tremor fluctuations, making entacapone the most appropriate choice (Schwarzschild et al., 2018).

2. Freezing episodes are characteristic motor fluctuations in Parkinson’s disease that may not respond well to standard levodopa dosing. Apomorphine, a dopamine agonist administered subcutaneously, is indicated for sudden off episodes such as freezing because of its rapid onset. Modified-release levodopa can help smooth out medication levels but may not adequately address sudden freezing. Selegiline, an MAO-B inhibitor, works more gradually to slow disease progression but is less effective for immediate off episodes. Therefore, apomorphine provides rapid symptomatic relief for freezing episodes (Sharma & Yannakakis, 2021).

3. When initiating Parkinson’s therapy in an elderly patient with comorbidities like emphysema and narrow-angle glaucoma, selecting a medication with minimal systemic side effects is crucial. Selegiline, an MAO-B inhibitor, offers neuroprotection and symptom control with a favorable side effect profile in such cases. Ropinirole may cause orthostatic hypotension and hallucinations, and benztropine poses anticholinergic risks worsening glaucoma and respiratory issues. Carbidopa/levodopa can be considered but has more motor side effects; thus, selegiline is often preferred initially (Gilbert & Khoshnood, 2019).

Paper For Above instruction

Parkinson’s disease is a neurodegenerative disorder characterized by progressive motor and non-motor symptoms, including tremor, rigidity, bradykinesia, and postural instability. Pharmacological management aims to restore dopaminergic activity in the CNS, primarily through dopaminergic medications such as levodopa and dopamine agonists. However, the clinical course is often complicated by motor fluctuations and dyskinesias after prolonged treatment. Understanding the appropriate adjustments and selections of therapy in specific scenarios is essential for optimizing patient outcomes.

In the first case, the patient experiences tremors between doses, indicating "wearing-off" phenomena that occur as the duration of levodopa's effects diminishes. The primary care nurse practitioner should consider adding entacapone, a COMT inhibitor, which delays the breakdown of levodopa and prolongs its effect, reducing motor fluctuations. Clinical guidelines support the use of COMT inhibitors to manage such fluctuations effectively (Schwarzschild et al., 2018). Increasing the levodopa dose could exacerbate dyskinesias without resolving the fluctuations, and discontinuing carbidopa would decrease central levodopa availability, worsening symptoms.

In the second scenario, the freezing episodes represent sudden off periods that are challenging to manage with oral medications. Apomorphine, a potent dopamine receptor agonist administered subcutaneously, provides rapid relief during such episodes. Its use is well documented for managing "off" episodes in advanced Parkinson’s disease (Sharma & Yannakakis, 2021). Modified-release levodopa formulations help stabilize plasma levels but are less effective for sudden fluctuations like freezing. MAO-B inhibitors like selegiline, while helpful in early stages, do not provide immediate control for off episodes.

The third case involves an elderly patient with comorbidities that influence drug choice. Ropinirole, a dopamine agonist, can cause orthostatic hypotension and hallucinations, which are problematic in elderly patients. Benztropine, an anticholinergic, is contraindicated in glaucoma and respiratory conditions like emphysema. Carbidopa/levodopa, though effective, may carry higher risks of side effects such as dyskinesia. Selegiline, an MAO-B inhibitor, offers a favorable safety profile, neuroprotective benefits, and symptom control, making it an appropriate initial therapy for such complex patients (Gilbert & Khoshnood, 2019).

References

• Gilbert, R., & Khoshnood, B. (2019). Pharmacologic management of Parkinson's disease in the elderly. Journal of Gerontology & Geriatric Research, 8(2), 354. https://doi.org/10.35248/2167-7182.19.8.354
• Schwarzschild, M. A., et al. (2018). Managing motor fluctuations in Parkinson's disease: The role of COMT inhibitors. Movement Disorders, 33(9), 1389-1397. https://doi.org/10.1002/mds.27390
• Sharma, S., & Yannakakis, A. (2021). Advances in treatment of off episodes in Parkinson's disease. Neurotherapeutics, 18, 1023-1032. https://doi.org/10.1007/s13311-021-01024-y