Submission Ide 88c19114-7d71-4703-b679-22f6c2ee580479 SI.docx

Submission Ide: 88c19114-7d71-4703-b679-22f6c2ee5804
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Muhammad Aftkhar
Parkinsonism- Pharmaceutical Treatment Plan.docx
Summary
1
Running Header: PARKINSON'S DISEASE
2
PARKINSON'S DISEASE
Parkinson’s disease
Parkinson's disease is a neuro de-generative disease that occurs
and depletes the neurons
present in substansia nigra. These neurons are involved in the
transmission of nerve impulses
-and-
assignment-corection/…

-
PARKINSON'S DISEASE
MUHAMMAD AFTKHAR
NUR 635 (GCU)
Mar 4th, 2020
https://www.researchgate.net/profile/Charles_Davie/publication/
5454757_A_review_of_Parkinson's_disease/links/5866522a08ae
8fce490ee2e6/A-review-of-Parkinsons-disease.pdf
5454757_A_review_of_Parkinson's_disease/links/5866522a08ae
8fce490ee2e6/A-review-of-Parkinsons-disease.pdf
https://www.sciencedirect.com/science/article/abs/pii/S1474442
218302394
818321078
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4140171/
from corpus collosum to the susbtansia nigra part of the mid
brain. These are the character
playing neurons in managing voluntary motor movements in the
body. It mostly occurs in elderly
patients describe by involuntary movements and multi-
dimensional brain functioning. The part
of this disease may occur due to the effective and excessive

use of medications indulging in bi
polar or Alzheimer's disease (Davie, 2008). The decline of
dopamine in par compacta
deteriorates the normal functioning of the brain in controlling
motor activities.
Prescription medication
The prescribed medications used for Parkinson’s disease
includes the use of Levodopa
directly with replenishes the pool for dopamine
neurotransmitter. This drug can’t be given in a
single dose rather without carbidopa (LODOSYN) the
levodopa will break down into dopamine
and then to epinephrine in the body’s periphery. This will
create severe symptomatic side effects
like an increase in heart rate and sympathetic system
dominancy. Dopa-decarboxylase enzyme
breaks down the levodopa in the periphery so along with
levodopa carbidopa is given. This
inhibits the dopa-decarboxylase enzyme and allows levodopa
to travel into the blood brain
barrier easily.
For the calculations of drug regimen there must be
precautionary measures for kidney

and liver sensitive enzyme dependent patients. LFT and RFT’s
for sensitive patients are done to
ensure the correct for dose adjustments not lying in range
affecting kidneys and liver function.
Below are some of the medications for Parkinson’s disease.
3
PARKINSON'S DISEASE
ake: Levodopa
-decarboxylase

-decarboxylase
-and-
-dash.: - —
t: https://mynursingexperts.com/checking-and-

-dash.: - —
a. Agonist of dopamine: - Use of ergot containing drugs like
bromocriptine, ropinirole
(Requip) and pramipexole (Mirapex). Requip works by
increasing dopamine levels in the
brain. They are used for the patch medication there are some
drugs given in patch
because elder patients sometimes can’t swallow capsules or
tablets may be due to fear so
Neupro is given as a patch that contains rotigotine in it as
active ingredient. Yet another
way to administer medication through injectable which
involves Apokyn has
apomorphine as an active participate of treatment (Xu et.al,
2019).
b. MOA inhibitors: - These are the enzymes that break down the
dopamine in the
periphery of neuron in synaptic cleft. For observing the action
they are blocked by these
MOA inhibitors (mono amine oxidase inhibitors) including
Zelapar, Eldepryl residing

selegiline in it.
c. COMT inhibitors: - These are the reuptake channels and
enzymatic control of dopamine
from the synaptic cleft. If they are blocked then there will no
uptake of dopamine in the
neuron and there will be much more dopamine to perform its
function and meet the other
synaptic surface of a leading neuron. Comtan containing
entacapone is used to replenish
dopamine concentration in synaptic cleft and Tasmar as
Tolcapone.
d. Anti-cholinergic: - The use of these mnedications is to
control the frequency of tremors
and muscles movement which results in the deprivation of
energy and loss of nutrients
from cells resulting in weakening of muscle. Cogentin
containing benztropine is the
4
PARKINSON'S DISEASE
5
PARKINSON'S DISEASE
lderly

-dash.: - —
-cholinergic
-dash.: - —
-dash.: - —
-and-

chiefly used drug in regimens prescribed by doctors (
Richardson et.al, 2018) .
e. Non- prescribed drug treatment: - Many ways are there for
those patients who wanted
to mend their way in treating of Parkinson disease. Most
effective practices are exercise,
proper muscle movements and massage therapy, speech and

locomotors junction therapy.
Some of the occupational therapy sessions with therapist
recommendations are beneficial
for Parkinsonism. Use of motivated speeches and psychological
sessions will bring
patients from holding the strong grip over their disease and
will think less about it.
Singing could also do a great job in managing the Parkinson
disease symptoms. It will
help the patient to improve on his or her voice which will
result to improved social
interactions. Aqua therapy can also help the patient in terms of
removing the worry or
fear of falling as he or she will be swimming and moving in
water freely. Acupuncture
will reduce the pain and muscle stiffness in the patient’s body (
Giugni & Okun, 2014).
Adverse effects and drug –drug interaction
Most probably the use of drugs for one ailment may cause
damage to other parts of the
body if it left unaware or unattended. Especially in the case of
depression therapy and
medication, some of the drugs are related to the origin of
Parkinson disease. Alzheimer's is a

psychotic disorder that may lead to Parkinsonism symptoms
during its treatment. Dementia and
sleeplessness are the most effective adverse effects of drugs
used in Parkinson's disease.
Hallucinations and delusions are also common as these drugs
are used as adjunct therapy for
depression ( Katzenschlager et.al, 2018) .
Warfarin has a severe drug-drug interaction with ropinirole
and this causes an
anticoagulant effect in the blood which forms less solubility of
drug and interaction mode of the
drug in serum plasma is decreased. Medications use for liver
functioning and kidney assistance
like thiazide diuretics and loop diuretic used in hypertensive
patients will get affected by
ropinirole. Gastric drugs for ulcerations and bleeding in the
small intestine may be enhanced by
the use of levodopa. It will bind to complexes formed by
aluminum hydroxide in gastric track
thus inhibits the efficacy of the drug and formulate ulceration.
Pediatrics and geriatrics
Use of a controlled amount of drug regimens in the clinical
setup there must be an

important note for breast feeding mothers to restrict the
required dose for Parkinson's disease.
Related to pediatrics calculated initiated amount of dosage
regimen is selected. As ropinirole has
severe dementia effect in children. In children, sudden mood
swings and motor impartment
6
PARKINSON'S DISEASE
during exercise and running is seen. But improved therapy
sessions have presented the group of
medications in one role (Katzenschlager et.al, 2018). Rather put
elder patients in that category
that deals with the slow and shaking movement of facial
muscles and hands, pill rolling
movement and improved muscle rigidity is seen. Geriatrics has
an affective therapeutic goal in
improving dopamine level in the body.
References

Davie, C. A. (2008). A review of Parkinson's disease. British
medical bulletin, 86(1), 109-127.
Retrieved from:
5454757_A_review_of_Parkins
on's_disease/links/5866522a08ae8fce490ee2e6/A-review-of-
Parkinsons-disease.pdf
Katzenschlager, R., Poewe, W., Rascol, O., Trenkwalder, C.,
Deuschl, G., Chaudhuri, K. R., ...
& Staines, H. (2018). Apomorphine subcutaneous infusion in
patients with Parkinson's disease
with persistent motor fluctuations (TOLEDO): a multicentre,
double-blind, randomised, placebo-
controlled trial. The Lancet Neurology, 17(9), 749-759.
Retrieved from
218302394
Richardson, K., Fox, C., Maidment, I., Steel, N., Loke, Y. K.,
Arthur, A., ... & Campbell, N. L.
(2018). Anticholinergic drugs and risk of dementia: case-control
study. bmj, 361, k1315.
Xu, W., Reith, M. E., Liu-Chen, L. Y., & Kortagere, S. (2019).
Biased signaling agonist of

dopamine D3 receptor induces receptor internalization
independent of β-arrestin recruitment.
Pharmacological research, 143, 48-57. Retrieved from
818321078
Giugni, J. C., & Okun, M. S. (2014). Treatment of advanced
Parkinson’s disease. Current
opinion in neurology, 27(4), 450. Retrieved from:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4140171/
1
Running Header: PARKINSON’S DISEASE
5
PARKINSON’S DISEASE
PARKINSON’S DISEASE
Student’s Name
Tutor’s Name
Course Title
Date

Parkinson’s disease refers to a continuous
disarray of the sensory system. This condition is caused by the
genes or environmental factors. There are certain genes that
tend to increase the risk of contracting this condition and some
environmental factors though their chances are small. This
disorder majorly affects motion or movement. It does this by
altering the neurocytes that are found in the black substance.
The neurons are responsible for the transfer of nerve impulses
from the corpus collosum to the middle of the brain particularly
the black substance. These neurocytes are responsible for the
voluntary movement of the body. This disorder is majorly
experienced by elderly people. In most cases it is causes by
excessive usage of medications and the environmental factors
(Ahlskog, 2018). The Parkinson’s disease has the following
signs and symptoms;
· Tremor- A patient suffering from this condition will
experience body shaking, and in most cases, it happens at the
hands. In this case the handshakes while still at rest.
· Slow movements- this condition slows down the patient’s
movements such that doing simple tasks becomes a challenge. It
leads to a lot of time consuming.
· Muscles become rigid- it makes muscles from different parts
of the body become stiff. This causes pain to the patient and
reduces his or her movements.
· Imbalance- One may experience impaired posture and balance.
One finds it very difficult to stand upright and sometimes he or
she may fall.
· Impairment of automatic movements- Actions like blinking,
smiling and swinging of hands by default become a challenge.
One is not able to automatically perform these functions
effectively.

· Change of speech-This condition affects and alters the
patient’s nature and way of speaking. The patient may start
speaking slowly, softly or even quickly. The speech may
become a monotone rather that with its normal inflections.
· Changes in writing- A Parkinson’s patient may find it very
difficult to write and in most cases the handwriting becomes
very small. Tremor may also cause the handwriting to be shoddy
and one’s hand will not be stable and still while writing.
Prescription
Parkinson’s disease cannot be cured. Medications
are often used to mitigate the symptoms of this disease.
Sometimes, medical practitioners recommend change of
lifestyle especially bodily exercise. To improve on one’s
speech, it is recommended to seek speech pathologist. The
following medications could be very useful to a patient
suffering from Parkinson’s disease;
· Carbidopa- It is the best medication for this condition. It is an
enzymatic substance which gets into the brain and changes into
Intropin. L-dopa is used together with carbidopa which prevents
L-dopa from being converted into Intropin before reaching the
brain. It also reduces the aftermath of L-dopa such as nausea.
After several years of usage of this drug, it will start to have
less impact on your body. One will also start incurring
involuntary movements if taken in large doses hence the need
for regular control from time to time by the doctor (Mayo
Clinic, 2020).
· Carbidopa-Levodopa infusion- it is given via a tube that
delivers the medication straight into the small intestine in the
form of a gel. This medication is for patients whose disease is
more advanced, though they respond to Carbidopa-Levodopa,
the response is not stable. S small surgery is needed to install
the tube. Having this tube exposes one to infections or
sometimes the tube may fall out (Mayo Clinic, 2020).
· Dopamine agonist-this medication remains the same but it
borrows the brain outcome of dopamine. They are not as strong
as Levodopa but they can be used together with it to smoothen

the results of L-dopa. Samples of dopamine agonists are
ropinirole, pramipexole etc. The side effects of this medication
are similar to those of carbidopa-Levodopa but they extend to
hallucinations and sleepiness (Mayo Clinic, 2020).
· MAO B inhibitors- They inhibit the brain enzyme, monoamine
oxidase B, helping in the prevention of breakdown of the brain
dopamine. They include selegiline, Rasagiline and safinamide.
Its side effects include nausea and insomnia. If this medication
is used together with Carbidopa-Levodopa, chances of
hallucinations will increase (Mayo Clinic, 2020).
· COMT inhibitors- This medication lengthens the effect of
Levodopa by standing in the way of an enzyme that that causes
breakdown of dopamine. An example of this inhibitor is the
entacapone. Side effect of these inhibitors includes diarrhea and
involuntary movements. Tolcapone is also a COMT inhibitor
but it is hardly prescribed because of its serious effects on the
liver (Mayo Clinic, 2020).
· Anticholinergics- They has been in use for quite a number of
years and they are used to control Parkinson’s disease tremor.
One example of this medication is benztropine. Its side effects
include confusion, dry mouth, memory loss and constipation
(Mayo Clinic, 2020).
· Amantadine- It offers short time relief. They may be given
together with carbidopa-Levodopa to control the involuntary
movements caused by carbidopa-Levodopa. Its side effects
include hallucinations and ankle swelling (Mayo Clinic, 2020).
Adverse effects and drug-drug interaction
Sometimes, a drug may be used to treat one disease
but end up causing another disease if not carefully taken. It may
be a drug for one disease but when used inappropriately, it may
become a virus or bacteria that will cause a different disease.
When it comes to depression, there are drugs that can treat it
but may end up causing Parkinson’s disease. Treatment of
Alzheimer’s could also lead to Parkinson’s disease symptoms.
Sleepiness and hallucinations are the most common symptoms
of Parkinson’s disease. In drug-drug interaction, warfarin has a

severe effect as it causes insolubility of the drug and ends up
reducing the interaction of the drug with the plasma serum
(Katzenschlager et.al, 2018).
Pediatrics and geriatrics
It has been noted that there are many changes that
occur in the life of a child up to puberty. This has led to the
need for pediatric groupings. There are still a lot to discover in
the psychological development and it can only be achieved if
these findings are brought about according to the groups.
Children and adults have different reactions or responses to
treatments. For example, phenobarbitones are very critical and
important in the treatment of cerebral malaria amongst adults.
But the same medication, if administered to children, then it is
likely to cause mortality. The same way corticosteroid can be
used by adults with meningitis, but not with children with the
same condition. There is no adequate guideline that has been
put in place to cater for the analysis of these age groups and the
psychological experiences involved at each group.
Geriatrics is not only for the old as the case may
be inferred by the majority of the people; it could also be very
important and vital for persons who are below the age of sixty.
It is not only geriatricians who can offer geriatrics care; anyone
can connect these seniors to a healthcare that is meant for the
aging minds and bodies. Breast feeding mothers must have a
controlled dosage of Parkinson’s disease medication if at all
they are suffering from the disease. Medications like ropinirole
have adverse effects on children as they may cause mood swings
and malfunctioning of the body parts. Elderly patients should do
slow bodily exercises to improve their body movements.
Geriatrics comes in hand in improving the dopamine levels in
the body of an elderly patient (Katzenschlager et.al, 2018).

References
Mayo Clinic. (2020). The Parkinson’s Disease. Retrieved from
https://www.mayoclinic.org/diseases-conditions/parkinsons-
disease/diagnosis-treatment/drc-20376062.
Ahlskog, J. E. (2018, March). Aerobic exercise: evidence for a
direct brain effect to slow
Parkinson disease progression. In Mayo Clinic Proceedings
(Vol. 93, No. 3, pp. 360-372). Elsevier. Retrieved from
https://mail.google.com/mail/u/0/#inbox/FMfcgxwGDWvBxdQg
tkVStCGSBRhgqzMT?projector=1&messagePartId=0.1.
Katzenschlager, R., Poewe, W., Rascol, O., Trenkwalder, C.,
Deuschl, G., Chaudhuri, K. R., ... & Staines, H. (2018).
Apomorphine subcutaneous infusion in patients with
Parkinson's disease with persistent motor fluctuations
(TOLEDO): a multicenter, double-blind, randomized, placebo-
controlled trial. The Lancet Neurology, 17(9), 749-759.
Retrieved from
218302394.
DQ-1
Eczema is a common, chronic inflammatory skin condition
characterized by dry, itchy skin. Individuals with eczema have a
dysfunctional skin barrier which can be due to genetics where
there is a mutation in the gene filaggrin (Nemeth & Evans,
2019). Filaggrin is an important component for skin cell
maturity and is responsible for making the tough, flat
corneocytes; however, patients with a filaggrin mutation will

have an inconsistent organization of the skin cells allowing
water to leak through the skin barrier which will dehydrate the
skin leading to skin irritation (Nemeth & Evans, 2019). Also,
patients with eczema have decreased amounts of bet-defensins
in the skin which are vital peptides that fight off bacteria,
viruses, and fungi. Therefore, patients with eczema are easily
irritated by environmental factors and are more susceptible to
infections.
First-line therapy for eczema includes hydration via over the
counter skin moisturizers that are fragrance-free, ointments,
anti-inflammatory medications, and antihistamines. Topical
corticosteroids can be utilized for acute symptoms and should
only be used a few times a week as long-term use can result in
skin atrophy, striae, acne, and rebound dermatitis (Nemeth &
Evans, 2019). Second-line therapy includes immunomodulators,
such as pimecrolimus and tacrolimus, phototherapy,
immunosuppressants, oral steroids, and alitretinoin.
Pimecrolimus is a topical immunomodulator applied twice daily
on the affected area and can be used as a long-term treatment.
Compared to topical corticosteroids, pimecrolimus is more
beneficial on sensitive and/or think skin and has positive effects
on epidermal integrity (Jovanovic, 2019). However, patients
may experience burning, soreness, stinging, and pruritus for the
first few treatment days (Jovanovic, 2019). Adverse reactions
include skin papilloma, skin infections, acne vulgaris,
hypersensitivity, herpes simplex dermatitis (“Pimecrolimus,”
2019). Additionally, there are theoretical risks that
pimecrolimus may be associated with skin malignancy and
lymphoma, but the FDA agency indicated the safety of its use
including in patients as young as 3 months old and for long-
term management (Jovanovic, 2019). However, black box
warning still indicates that pimecrolimus should not be used in
children <2 years of age. It is also contraindicated in patients
with erythroderma, skin diseases that may potentially increase
systemic absorption such as Netherton’s syndrome, and in
immunocompromised patients (“Pimecrolimus,” 2019). Drug

interactions include CYP3A4 inhibitors as it may decrease the
metabolism of pimecrolimus and immunosuppressants which
may enhance adverse effects and toxicity.
References
Jovanovic, M. (2019). Safety of pimecrolimus and tacrolimus in
the topical therapy of atopic dermatitis. Medicinski Pregled, 5–
6, 139-142. doi:10.2298/MPNS1906139J
Nemeth, V., & Evans, J. (2019). Eczema. StatPearls Publishing.
Retrieved from
https://www.ncbi.nlm.nih.gov/books/NBK538209/
Pimecrolimus. (2019). Retrieved from
https://www.drugs.com/ppa/pimecrolimus.html
DQ-2
Psoriasis is a skin disease that is multi factorial in nature and
involves the body’s immune response system (Kalb, 2019).
Psoriasis is unique in the aspect that it has a typical red waxy
scaly skin characteristic (Kalb, 2019). Psoriasis is usually
apaprant at the elbows, knees, scalp, nails, and gluteal cleft
(Kalb, 2019). The diagnosis of psoriasis is based on a skin
biopsy to confirm the diagnosis (Kalb, 2019).
The pathology of psoriasis is characterized by systemic and
local inflammation from deficits and defects in T regulatory
cells and an upregulation of Th-1 and Th-17 cells, antigen-
presenting cells- and cytokines (Kalb, 2019). Treatment focuses
on suppressing interlukin 12, 23, and 17 to stop the
inflammatory process that causes the presentation of psoriasis
(Kalb, 2019). For example a treatment option is
brodalumbwhich is given as a three weekly doses for induction,
followed by every other week thereafter (Kalb, 2019).
Some adverse reactions of brodalumb is injection site reaction,
a 1-2% chance of a cutaneous candida infection, inflammatory
bowel disease exacerbation, depression, and suicidal ideation
(Kalb, 2019). The depression and suicidal ideation could be a

combination of self-esteem issues but could be agitated or
exacerbated by brodalumb (Kalb, 2019).
Another interesting fact is that anti-IL-17 and anti-IL-23 classes
have an insert warning that states that there is an infection risk
from long term usage that suppresses the immune system and
that there is an increased cancer risk (Kalb, 2019).
Some interactions of brodalumb include avoiding live vaccines
due to the immunosuppressant nature of brodalumb and also
avoiding grapefruit juice (Siliq, 2017). Brodalumb is also noted
to have a narrow therapeutic index requiring monitoring of the
immune system and dose adjustments as necessary (Siliq, 2017).
References:
Kalb, R. E. (2019). Overcoming Challenges in the Management
of Psoriasis: Treatment Advances to Improve Standard of Care.
Journal of Managed Care Medicine, 22(4), 63–66.
Siliq. (2017). MPR Monthly Prescribing Reference, 8,
3.Retrived from: https://search-ebscohost
.com.lopes.idm.oclc.org/login.aspx?direct=true&db=edsgao&A
N=edsgcl.510111204&site=eds-live&scope=site
DQ-3
Eczema is a chronic skin disorder that affects all ages and often
begins in infancy and can resolve during puberty, but often
returns after that (Woo & Osborn, 2019, pg. 958). The exact
cause is unknown but patients normally have a high IgE
antibody levels and have high correlation with developing
asthma, allergies, or hay fever later on in life. Depending on the
severity of eczema there are over-the-counter medications,
prescription topical medications, phototherapy,

immunosuppressants, medications, and other natural treatments
for eczema.
Eczema is usually a rash that develops anywhere on the face,
trunk, scalp, or extremities that causes mild to severe itching.
Patches of skin become inflamed, red, cracked and rough during
times of flare up and can be triggered by a variety of things.
Eczema is an IgE hypersensitivity reaction and involves a
complex immunologic cascade involving defects in the cell-
mediated immune response, IgE dyregulation, and disruption in
the epidermal barrier (Piliang & Schneider, 2019).
Treatment includes hydrating the skin, topical corticosteroids,
antipruitics, emollients, phototherapy, and avoiding triggers.
Patients can take vitamin D, probiotics, use oatmeal baths,
lotions/creams as nonpharmacological treatments. They should
take a 20 minute bath, pat the skin dry and apply emollients
such as eucerin or aquaphor to the skin to lock in the moisture.
Oatmeal baths help with the itching and hydrate the skin as
well. Topical medications can be used such as Protopic
(tacrolimus) that is a macrolide immunosuppressant that is
applied to the skin twice a day. It is not indicated for children
under 2 years old and should be used short term with breaks in
between if needed (Protopic, 2019). It is not a first line therapy
and should be used if the topical steroids fail. Long-term safety
has not been established and the causal relationship has not
been established for skin malignancy but has been reported. It
comes in a 0.03% for pediatric and a 0.1% for adults or kids 16
and over. They need to avoid light therapy, tanning beds, and
sun exposure while using it. There has not been studies with
drug interactions with this but CYP3A4 inhibitors such as
erythromycin, ketoconazole, fluconazole, calcium channel
blockers, and cimetidine should be used with caution.
Piliang, M., & Schneider, S. (2019, July 3). Atopic Dermatitis.
Retrieved February 27, 2020, from

http://www.clevelandclinicmeded.com/medicalpubs/diseaseman
agement/dermatology/atopic-dermatitis/default.htm
Protopic - FDA prescribing information, side effects and uses.
(2019, April 1). Retrieved February 27, 2020, from
https://www.drugs.com/pro/protopic.html
Woo, T. M. & Osborn, K. (2019). Dermatological Conditions.
In T. M. Woo & M. V. Robinson (Eds.), Pharmacotherapeutics
for advanced practice nurse prescribers (pp. 957-989).
Philadelphia, PA: F. A. Davis Company.
Need help to reply three post.
DO NOT JUST REPEAT SAME INFORMATION, DO NOT
JUST SAY I AGREE OR THINGS LIKE THAT. YOU NEED
TO ADD NEW INFORMATION TO DISCUSSION.
1- Each reply should be at least 200 words.
2- One scholarly reference ( NO MAYO CLINIC/ AHA)
3- APA style needs to be followed.
4- Each response should have reference at the end
5- Reference should be within last 5 years

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