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Summary Neurology Key Points for PEBC Exam
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Key points on neurology material required to be successful on the PEBC MCQ Exam.
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NEURO SHORT LESSONParkinson’s Disease
Patho Loss of DA neurons in SN
Dx Bradykinesia w at least 2 of: rigidity, resting tremor, postural instability
Drug Bilat rather than asymm
Aph (phenothiazines, butyrophenones, risperidone), antiemetics (metoclopramide,
prochlorperazine), reserpine, alpha-methyldopa, VPA, Li, TCA, SSRI
Non Pharm PT edu, staying active, allied HCPs, surg (DBS, lesioning)
Pharm Initiate when disease interferes w activities
- Avoid DA in elderly (psych ADR)
- Avoid anticholinergics in elderly
- Avoid L-DOPA in younger PTs
Mild/early Consider MAOI
disease
Mod-severe <60yo: DA
disease >60yo: L-DOPA (only agent shown to ↓ mortality)
Agents MAO-BI Mild disease or as adj: may slow progression, improve motor sx, wearing off
- Selegiline has amphet metabolite, ODT form (avoids 1st pass)
- Rasagiline has ↑ duration (OD v BID), more selective (avoids Tyr inrx)
ACh For tremor, initial therapy or adj, improves dystonic sx
Taper gradually
Amantadine Early disease for tremor, ↓ choreic movement (dyskinesia)
- Renally adjust, rebound sx w DC
DA Prolongs effective rx period, useful in younger PTs, useful for pts who cannot tolerate high
dose of L-dopa
- Titrate over 4-6wk
V L-DOPA: ↑ GI upset, orthostatic hypotension, psych
Ergots: bromocriptine, pergolide
- Pergolide OD, bromocriptine BID
Non-ergots: pramipexole, ropinirole, rotigotine
- Rotigotine TD patch
- Pramipexole renal adj
COMTi Extends L-dopa duration periph(use w L-dopa) to manage wearing off
- ↓ L-DOPA when initiating
Give TID w L-DOPA
- Considered more effective than CR L-DOPA
Brown urinary discolouration
L-DOPA Combined w periph decarboxylase inh (carbidopa, benserazide) to cross BBB
- Most effective med for PD
- Assoc w earlier onset of dyskinesias (peak dose) and motor flux (wearing off)
Dyskinesias risk: ↑ doses of L-DOPA, ↑ duration of L-DOPA, younger age of
onset, severity of degeneration, female
- Delayed response with CR formulations
Wearing off: Advancing disease, duration of action shortens dt loss of neuronal storage
capacity + short half-life of L-dopa
Delayed on: chew/crush w water, regular tab on empty stomach (no prot)
Morning freezing: regular dosage form, bedtime CR, baclofen, selective botox
Freezing: non-pharm, physio
, Monitoring DC in following order: anticholinergics(taper)/TCAs/anti-H MAO-B amantadine (taper) DA
(taper) COMT ↓ L-DOPA dose
- Add quetiapine, clozapine if disruptive hallucination/psychosis (avoid olanzapine)
- Taper to avoid parkinsonism-hyperpyrexia syndrome
N/V: domperidone (avoid metoclopramide)
Depression: avoid SSRI/SNRI/bupropion if MAO-B
Restless Leg Syndrome
Patho Intermittent: <2x/wk
Chronic persistent: >2x/wk
Drug OH, ADs, APh, caffeine, metoclopramide, nicotine, TCAs, APhs, tramadol
NonPharm Mild sx
Mental alertness, refrain from OH/caff/nicotine, stretching, hot baths, avoid sleep deprivation
DC: ADs, APHs, DA-blocking antiemetics, sedating antihistamines
PCDs?
Intermittent RLS
L-DOPA:
BZD: for sleep quality
Opioids: not relieved by other meds (use low potency)
Chronic Persistent RLS
DA: for comorbid depression, excessive wt, cog impairment, fall risk
Pharm
GABA ddx: for severe sleep disturbances, comorbid insomnia/anx, painful RLS, hx compulsive
behavior
- Consider pregab for those who develop augmentation by DAs
Refractory RLS
Unresponsive to monotherapy w first-line agents for chronic persistent RLS
Combo therapy
Multiple Sclerosis
Dx No sp tests, r/o VitB12 def
McDonald criteria: 2 attacks anytime x >24h, sep by > 30d, +/- confirmatory MRI
- RRMS: most common, likely to respond to immunomod
- SPMS: progressive course follows initial RRMS
- PPMS: steady worsening
NonPharm Exercising, avoid high heat, physio/stretching/massage
1000 IU Vit D/d
Pharm First Line
Interferon beta:
- depression
Glatiramer acetate:
DMF: rare pml
- Monitor: CBC, LFTs, urinalysis
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