A clinical pharmacy case Presentation on Parkinson disease. ( Of a old lady admitted in ITU with Parkison disease along with UTI)

1. CASE PRESENTATION
By (Dr) RUTH RAJAN
6th Pharm.D
VINAYAKA MISSION COLLEGE, SALEM
GUIDE - DR ARPAN DUTTA ROY
Clinical Pharmacologist (AMRI)

2. NAME : Mrs Ranu Sen AGE : 85yrs SEX : Female
HEIGHT : 51m WEIGHT: 45kg BMI: 20
DOA : 18-05-2018 IP NO : AM10064852

3. Chief Complaints: drowsiness
decreased appetite
drawing of saliva from
mouth,
fluctuating bp.
Known case of parkinsonism, dementia,
depression , hypothyroidism ,
On examination: BP : 90/60mmhg
PR : 96mm/hr

4. • Past Medical History : Parkinsons, Dementia,
Depression,
Hypertension
• Past Medication History : Lonazep
Quitipine
Rosalect
Ganaton
Telace
Aspirato
Doneptale
Thyronorm

5. • LAB INVESTIGATION :
Sl No TESTS RESULT
18/05/2018
BIOLOGICAL
REFERENCE
1 HAEMATOLOGY:
Haemoglobin
RBC Count
PCV
MCV
MCH
MCHC
platelet count
TLC
Neutrophil
Lymphocyte
Monocyte
Esinophil
Basophil
ESR
9.7gm/dl
3.01m/cum
29.50 %
98.0 fl
32.2 pg
32.9 g/dl
2.50 lakhs/ul
6.7 thou/cumm
87.0 %
10.0 %
2.0%
1.0%
0.0%
106mm/1st hr
12.0 - 15.0
3.8 - 4.8
36.0 – 46.0
83.0 –101.0
27.0 – 32.0
31.5 – 34.5
1.5 - 4.1
4,5 - 11.0
40.0 – 80.0
20.0 – 45.0
2.0 - 10.0
1.0 - 6.0
0.0 - 2.0
0 – 35
2 TSH 7.57uU/ml 0.27-4.2
LABORATORY DATAS ( )

6. Slno Tests Results
18/05/2018
Biological Reference
3 URINE TEST
Pus cells
R.B.C
Epithelial cells
Bacteria
Plenty
3 – 4/HPF
4 – 5/HPF
present
4 Urea 23.0 mg/dl 15.0 – 39.0
5 Creatinine 0.85 mg/dl 0.6 – 1.0
6 Calcuim 8.54 mg/dl 8.5 – 10.1
7 Phosphorous 3.44 mg/dl 2.5 – 4.5
8 Magnesium 1.74 mg/dl 1.8 – 2.4
9 Sodium 140.2mEg/dl 135.0-145.0
10 Potassium 4.46mEg/dl 3.5 – 5.1
11 CRP 24.5mg/dl 0.0 – 0.5
12 LFT
Total bilirubin
Total protein
Total albumin
0.31 mg/dl
5.82 g/dl
2.77 g/dl
0.2 – 1.0
6.4 – 8.2
3.2 – 4.6

7. Aerobic culture test
On 21/MAY/2018 On 22/MAY/ 2018
Urine: E-coli Blood : burkholderia capacia
ANTIBIOGRAM: Sensitivity test ANTIBIOGRAM-Sensitivity test
Amoxy-clav – 8 MIC Ceftazidime- 4MIC
Piperacillin-tazo – 4 MIC Cefepime- 4MIC
Cefroperazone-sulb – 8MIC Ciprofloxacin- 0.25MIC
Imipenem -0.25 MIC Levofloxacin- 0.5MIC
Merpenem- 0.25MIC Gentamicin- 1MIC
Ercapenem-0.5MIC Amikacin- 2MIC
Gentamicin- 1MIC Cotrimoxazole- 20MIC
Amikacin- 2MIC Minocycline-1MIC
Nitrofuratoin- 16MIC
Colistin- 0.5 MIC
Fosfomycin- 16MIC
MICROBIOLOGY TEST

8. CT SCANS (19/05/2018)
Impression : Moderate cerebral cortical atrophy.
Mucosal thickening with inspissated secretion in sphenoid Sinus
CARDIOLOGY EXAMINATION REPORT
ECHO REPORT (18/05/2018)
•Grade 1 LV diastolic dysfunction.
• Aortic sclerosis
•Trace TR
ECG REPORT
(19/05/2018)
• Rate : 101bpm
• Conclusion: sinus tachycardia
(21/05/2018)
• Rate: 85bpm
• Conclusion: resting ECG with normal limits.
PORTABLE USG SCREENING (21/05/2018)
•Mild cystitis
•Small left kidney
PORTABLE CHEST X-RAY- Normal

9. • Dementia
• Depression
• Parkinsons
• Hypothyroidism
• Hypertension
• UTI
DIAGNOSIS

10. • On 18/5/2018: BP fluctuation, drowsyness, left eye dropsy, very
slow to respond.
• On 19/5/2018: No verbal communication, febrile spike yestrdy,
bedwetting,not talking oral feed, CRP increased, ryle tube, stool
not passed.
• On 20/5/2018: alterness better, haemodynamically stable, urine
plenty, pus cells, continous bedwetting, physiotherapy –leg
danglip done.
• On 21/5/2018: haemodynamically stable, urine output,
hyperactive as per relative, not communicating, sinus tachycardia,
unable to swallow tablets, conscious, restless, no RT feeds.
• On 22/5/2018: overnight awake, restlessness persistants,
tolerating RT feeds. Conscious, confused, blackish discolouration
over back, bedwetting,leg danling.
INVESTIGATION

11. • On 23/5/2018:restless, communicating, Rt tube, bedside leg
dangling.
• On 24/5/2018: alert, restless, bedwetting, haemodynamically
stable, leg danglip done, tolerating oral feed.
• On 25/5/2018: alert, had hypotension, hypoglyceamia,
bedwetting, taking oral feed, dementia, confused,weakness.
• On 26/5/2018: low BP, urine not passed last night, stress
cardiomyopathy, restless during night, Rt feeds.
• On 27/5/2018 to 29/5/2018: haemodynamically maintaining,
restless at night urine output adequate.
• On 30/5/2018: not obeying, very restless, tachycardia,
bedwetting, very agigated

12. TREATMENT
PLAN & CARE

13. sln Drug Name Generic Name Dose ROA FREQ Duration
1 Inj pan
Tab pan
pantaprazole 40mg Iv
p/o
OD Startd-18/5 Stop-20/5
Started-21/5
2 Inj optineuron
Tb optineuron
Vit B complex 1amp
1 tab
iv OD
OD
Startd-18/5 Stop-19/5
Startd- 20/5Stop-31/5
3 Tab
Thyronorm
levothyroxine 25mcg p/o OD Started- 18/5
Stopped- 31/5
4 Inj zosyn Piperacillin+
tazobactum
4.5mg iv stat Started- 18/5
5 Tab Rasalect Rasagiline 1tab p/o HS Started- 18/5
Stopped- 31/5
6 Tab syndopa Carbidopa +
levadopa
110mg p/o QDS Started- 18/5
Stopped- 31/5
7 Tab Quitipin quetipine 12.5mg p/o HS Started- 18/5
Stopped-24/5
8 Inj tazar Piperacillin+
tazobactum
2.25mg iv 6thhrly Started- 18/5
Stopped-22/5
9 Inj para Acetaminophen 100ml iv sos Startd-18/5 Stop-22/5
10 Inj Mgso4 Mgso4 2mg iv Started- 19/5

14. Sln Drug name Generic name Dose ROA Freq Duration
11 Inj human
albumin
Plasma protein 20% in
100ml
iv over8h
rs
19/5/2018
12 P Enema Phosphate stat 19/5/2018
13 Monurol Sachet fosfomycin 3mg r/t stat Started-19/5
Stopped-
14 Tab admenta Memantine 5mg r/t OD Started- 19/5
Stopped-31/5
15 Tab donep donepezil 2.5mg r/t OD Started- 19/5
Stopped-31/5
16 Syp cognitam piracetam 10ml r/t BD Started-19/5
17 Syp laxit plus Liq paraffin+
Mgso4
3 tsp p/o Hs Started- 20/5
Stopped-23/5
18 Tab Quatan quetipine 1/2tab p/o stat Started- 20/5
19 Inj Mgso4 Mgso4 4mg in
100ml NS
iv Over
4thhrly
Started- 21/5
Stopped-22/5
20 Neb levolin levosalbutamol 1 resp TDS 23/5/2018

15. Sln Drug name Generic name Dose ROA Freq Duration
21 Inj meronem meropenem 1gm iv OD Started- 22/5
Stopped-23/5
22 Syp potklor KCL 3 tsp Started- 22/5
23 Tab Rantac Ranitidin 150mg p/o BD Started- 22/5
Stopped-31/5
24 Inj milifast minocycline 100mg iv BD Started- 23/5
Stopped-29/5
25 Inj PCM Acetaminophen 1gm iv SoS Started-
Stopped-
26 Syp dulphac lactulose 3 tsp r/t HS Started- 23/5
Stopped-31/5
27 Inj lonazen Lorazepam 0.25mg rt HS Started- 24/5
Stopped-31/5
28 Inj Dextrose Hydrous dextrose 25% in
100ml
iv stat Started-24/05
29 K bind sachet Calcium
polystyrene,
sulphonate
1 sac bd Started-23/5

16. Sln Drug name Generic name Dose ROA Freq Duration
30 Inj calcuim
gluconate
Calcuim
gluconate
10ml iv stat Started-23/5
31 Inj human
actrapid
insulin iv stat Started-23/5
32 Inj nor adrenaline noradrenaline 1.6ml
33 Inj cort hydrocortisone 100mg iv stat Started-25/5
34 Inj rantac ranitidine 1amp iv stat Started-25/5
35 Tab atorva Atorvastatin 10mg p/o HS Started- 25/5
Stopped-31/5
36 Tab ecosporin Aspirin 150mg p/o BD Started- 25/5
37 Tab urivoid Bethanechol 1 tab p/o OD Started- 26/5
38 Tab cardivas Carvedilol 3.125m
g
p/o OD Started- 27/5
39 Tab ativan lorazepam 1mg p/0 sos Started-30/5
Stopped-31/5

17. Suspected Drug Interaction and its management-
 Quetiapine+Levadopa : quetiapine decreases effects of levadopa by
pharmacodynamic antagonism reaction. Avoid or use alternative drugs. (
Mangement -Quetiapin safe drug, Dosage Interval 1hr)
 Rasagiline+Levadopa : pharmacodynamic synergism. Monitor closely. Risk of
acute hypertension.monitor BP and avoid Tyramin
 Ranitidine+memantidine : ranitidine increases level or effect of memantidine
by decreasing renal clearance. ( Dosage interval 4 to 5 hr, better to use ppi if
possible because no enzymetic interction and half life is 1to 2 hr)
 Pantaprazole+levothyroxine : pantaprazole decreases level of levothyroxine
by gastric ph.( Mangement -Dosage Interval 3hr)
 Piracetam+Levothyroxine : This combination produce confusion, sleep
disorder.( Unknown MOA)
Pharmacist Intervention

18. Suspected Drug Food Interaction and Management –
 Avoid taking Minocycline with dairy products because it
decreases the absorption.
 Avoid foods containing a very large amount of tyramine like
ageg cheese with Rasagiline. (Eating these foods while you are taking selegiline can raise
your blood pressure to dangerous levels. This may cause life threatening symptoms such as sudden and severe
headache, confusion, blurred vision, problems with speech or balance, nausea, vomiting, chest pain, seizure
(convulsions), and sudden numbness or weakness (especially on one side of the body)
 Thyronorm should be taken with empty stomach. Food, milk ,
tea, caffeine decreases levothyroxine by inhibiting GI
absorption.
 To decrease the risk of side effects of carvedilol, take medicine
with food.
Dosing accuracy of Drugs –
 Based upon creatinine clearance dose of inj Zosyn should be
2.25g iv q6hr or 3g iv q6hr.

19. Any specific information about any drug –
 Carvedilol :sudden stopage warnings, low heart rate warning,
low blood pressure warnings. Recommends to take low dosage
then slowly increase it.
 Rasagiline : exacerbation of hypertension may occur during the
treatment with rasagiline. Dosage adjustment may be necessary.
 Dopamine agonists may impair the systemic regulation of blood
pressure with resultant orthostatic hypotension during dose
escalation. Therapy with dopamine agonists should be monitored
carefully in patients with parkinsons disease since they might not
have an impaired ability to respond to an orthostatic challenge
and also in receiving antihypertensive drugs.
 Patients with major psychotic disorder should not be treated with
dopaminergic antiparkinson agent because of risk of
exacerbating psychosis.

20. • Quetiapine : the use of atypical antipsychotic agents has been
associated with orthiostic hypotension, hyperglyceamia, lipid
levels, priapism, constipation, drowsiness and syncope.
• Quetiapine is not approved for use in psychotic conditions
related to dementia. It may increase the risk of death in older
adults with dementia related conditions.
• Cholinesterases inhibitor(donepezil/memantine)+parkinsonism:
symptoms of parkinsons disease may be exacerbated with the
increase in cholinergic activity. And also increase in gastric acid
secretion and gastric contraction.
• Benzodiazepines(includes lorazepam): benzodiazepam depress
the central nerous system and may cause or exacerbate mental
depression. Therapy with benzodiazepines should be
administered cautiously in patient with history of depression or
other psychiatric disorder. Monitor signs of paradoxial reaction
in patients.

21.  Tab rantac 150mg *15 days
 Tab thyronorm 37.7mcg once daily empty stomach
 Tab rosalect 0.5mg at night to continue
 Tab syndopa plus 125mg five times daily to continue
 Tab admenta 5mg once daily at10am
 Tab donep 5mg daily at 12 noon
 Tab quitipin 25mg twice daily – to be tapered at home once rest
decreases
 Tab lonazep 0.25mg at night to continue
 Tab atorva 10mg at night to continue
 Tab ativan 1 mg if agitated
 Syp potklor10ml thrice daily for 2 days-repeat serum potassium
therafter
Drugs on Discharge

22. Drug based ( Pharmacological Councelling ) :
 while taking rasagiline, quetiapine notice symptoms like
agitation,hostility,depression,thoughts about dying or changes in thinking.
 Avoid foods containing a very large amount of tyramine like ageg cheese.
 Caution about paradoxial signs in patients when taking lorazepam.
Disease based :
 Educate patient and caretakers about disease and to record the medication doses
and administration times and duration of “ on” and “off” period.
 Monitor the symptoms, side effects and activities of daily living and individualize
therapy.
Lifestyle based ( Non- Pharmacological Councelling ) :
 Bed rest
 Avoid falling
 Avoid dairy products like cheese , ghee, butter, milk.
PATIENT DISCHARGE COUNSELLING

23. DEFINITION
Parkinsons is a progressive disease of the nervous system marked by tremor,
muscular rigidity, and slow, imprecise movement, chiefly affecting middle-aged and
elderly people. It is associated with degeneration of the basal ganglia of the brain and a
deficiency of the neurotransmitter dopamine.
ETIOLOGY
Enviromental factors: pesticides, caffine, cigarette, disease process
Genetic factors
Brain injury
CLINICAL MANIFESTATION
Temor
Rigidity
Bradykinesia
Dyskinesia
Motor symptoms
Postural inability
Giat impairment
Pill-rolling
DISCUSSION

24. PATHOPHYSIOLOGY
Physiologically, the symptoms associated with Parkinson’s disease are the result
of the loss of a number of neurotransmitters, most notably dopamine. Symptoms
worsen over time as more and more of the cells affected by the disease are lost.
The course of the disease is highly variable, with some patients exhibiting very
few symptoms as they age and others whose symptoms progress rapidly.
Parkinson’s is increasingly seen as a complex neurodegenerative disease with a
sequence of progression. There is strong evidence that it first affects the dorsal
motor nucleus of the vagus nerve and the olfactory bulbs and nucleus, then the
locus coeruleus, and eventually the substantia nigra. Cortical areas of the brain
are affected at a later stage. Damage to these various neuronal systems account
for the multi-faceted pathophysiologic changes that cause impairments not just to
the motor system but also to the cognitive and neuropsychological systems.
DIAGNOSIS
•Neurological and physical examination
•Imaging test like MRI, ultrasound of brain, SPECT and PET.
TREATMENT
Non pharmacological treatment
•Exercise
•Nutrition
•Psychosocial support

25. Pharmacological treatment
•Drugs affecting brain dopaminergic system
(a) dopamine precusror : Levadopa
(b) pheripheral decarboxylase inhibitors : Carbidopa, Benserazide
(c) dopaminergic agaonist : Bromocriptine, Ropinirole, Pramipexole.
(d) MAO-B inhibitors : Seligiline, Rasagiline.
(e) COMT inhibitors : Entacapone, Tolcapone.
(f) Glutamate (NMDA receptors) antagonist (dopamine faciliators) :
Amantadine.
•Drugs affecting brain cholinergic system :
(a) central anticholinergics : Trihexyphenidyl(benzhexol), procyclidine.
(b) antihistamines : orphenadrine, promethazine.

26. Thank You