Spending a good chunk of my time in geriatrics, we get into these situations where there are options on the table, but we may not like any of them. Selecting antipsychotics in Parkinson’s is one of those crappy situations. If you remember the pharmacology and physiology of Parkinson’s, we have a shortage of dopamine in the brain. This is an oversimplification, but I think it helps create a simple visual. If you remember in schizophrenia, we have an overabundance of dopamine.
In Parkinson’s we naturally try to replace the deficient dopamine stores by giving carbidopa/levodopa (Sinemet), the gold standard in Parkinson’s care at this time. In schizophrenia, we use dopamine blocking agents. These are called antipsychotics. Risperidone, quetiapine, aripiprazole are a few common examples of antipsychotics.
In a patient with Parkinson’s disorder, there may be symptoms of hallucinations (usually visual) and delusions. This may be due to the disease itself and/or it may be due to excessive dosing of Sinemet. In patients that have hallucinations and are receiving Sinemet, the first step is usually to look at the dosing and potentially reduce it. This reduction in Sinemet has the potential to help reduce the hallucinations, but it can also increase the symptoms of Parkinson’s disease. Remember the acronym TRAP for symptoms of Parkinson’s disease (tremor, rigidity, akinesia, and postural instability).
In the event that reducing the Sinemet dose if not effective for management of hallucinations, or this reduction leads to problematic Parkinson’s symptoms, we may consider adding an antipsychotic medication. We generally try to avoid the more potent dopamine blocking agents like the typical agents (haloperidol etc.) and some of the atypicals (risperidone). Quetiapine and clozapine are two antipsychotics in Parkinson’s that would have the least impact on the disease. Because of this, the likely antipsychotic of choice in Parkinson’s disease is quetiapine.
If you are looking for more clinical pearls on the antipsychotics, be sure to check out this podcast.
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Umm Nuplazid?
It’s crossed my mind before, but really hard to justify a $3k/month drug. Have you recommended it in any situation? It also has some negative press recently https://www.cnn.com/2018/04/09/health/parkinsons-drug-nuplazid-invs/index.html
In theory Nuplazid should be ideal for PK psychosis. As I understand, it’s an antipsychotic without the dopamine block you want to avoid for PK. The mechanism is unique, an inverse serotonin agonist and antagonist. There are psychiatrists around the Seattle area where I work that are using it in the LTC setting. I do bring it up an option for PK psychosis instead of low dose Seroquel. Thanks for sharing that article, it was not on my radar at all. Nuplazid carries the same black box warning for elderly/dementia risk of mortality. Seems the risks might be understated?
This is particularly troubling as the ones experiencing the hallucinations and delusions are usually further along in their disease progression and therefore are often elderly. There is a new drug out called pimavanserin (Nuplazid) that is indicated for hallucinations and delusions in the PD population but it has a black box warning about increased risk of death in elderly PD patients. I was curious if you had any experience withpatients using it or know any clinicians that have. It’s a rather unfortunate BBW seeing as it may very well prevent that drug’s use in the population that needs it most.
Cost has deterred its use in my practice and even if written for, I have not seen it used at this point. I am generally a slow adopter of medications until they are used for a while because of stories like this – https://www.cnn.com/2018/04/09/health/parkinsons-drug-nuplazid-invs/index.html
My husband (who has had PD for 22 years) has been taking Nuplaxid for several months and it has really helped his hallucinations. Delusions, of course, are another story. He’s recently become aggressive and now has ammonia in his blood which is not helping matters.