2. DEFINITION
Parkinson's disease is degenerative disorder of
the CNS dopaminergic neurons which shows
mainly motor and sometimes cognition (thinking)
related symptoms.
movement-related (motor)
shaking, rigidity, slowness of movement and
difficulty with walking
Cognitive problems
Dementia
3. Causes
• Parkinson is caused due to imbalance of
dopamine(DA) and acetylcholine (Ach)
• Ach and DA need to be balanced for smooth
movement. DA causes muscle relaxation while
Ach causes contraction.
• Reduction of DA, in the basal ganglia results in
imbalance of those two and causes motor
disorders
• In some cases, at later stages of the disease
reduction of Ach which is also involved in learning
and attention leads to dementia
4.
5. Classification
• Anti-Cholinergic drugs: atropine, Benzhexol*
Reduces acetylcholine effects (treatment for tremors in early stages)
• Cholinesterase inhibitors: Rivastigmine
Promotes acetylcholine effects (treatment for dementia in later stages)
• Dopamine precursors: levodopa*
Prodrug of dopamine
• Dopamine decarboxylase inhibitors: Carbidopa, benserazide
Inhibits peripheral metabolic degradation of dopamine
• Catechol-O-methyl Tranferase (COMT) inhibitors:
Entacapone
inhibits COMT based metabolism of Levodopa
• Dopamine agonist: bromocryptin, Amantadine
Promotes dopamine effect in the brain.
6. Anticholinergics
• Anticholinergic medicines block cholinergic nerve
impulses that help control the muscles of the
arms, legs and body by inhibiting binding of
acetylcholine with it’s receptors
• For normal motor or muscle control, the effects
of acetylcholine and dopamine need to be
balanced. In Parkinson dopamine levels decrease
but Acetylcholine levels remain same.
• Anticholinergic medicines decrease levels of
acetylcholine to achieve a closer balance with
dopamine levels.
7.
8. Benzhexol (Trihexyphenidyl)
• It is an antimuscarinic drug that blocks Ach effect on M1
receptor
• In Parkinson DA and Ach levels are imbalanced that causes
motor defects. DA lvls are reduced while Ach lvls remain
constant. Benzhexol lowers Ach levels and maintains the
balance
• Trihexyphenidyl is used for the symptomatic treatment of
Parkinson's disease in mono and combination therapy with
L-Dopa
• Also used to control drooling of children with cerebral palsy
(cebebrum paralysis that effects movement)
• In older patients with Parkinsonism it can increases chances
of dementia since Ach is involved in cognition too
9. Cholinesterase inhibitors
• Cholinesterase inhibitors are designed to increase
levels of acetylcholine, a chemical messenger
involved in memory, judgment and learning,
traits which are lost in dementia stage of
Parkinsonism which only occurs sometimes at a
later stage
• Cholinesterase inhibitors do not stop the
destruction of dopaminergic nerve cells. Their
ability to improve symptoms eventually declines
as brain cell damage progresses.
10. Rivastigmine
• It is a acetylcholinesterase/butyrylcholinesterase
inhibitor used to treat dementia that sometimes
occurs at later stage of Parkinson
• It increases lvl of Ach by blocking it’s degradation
from the enzyme acetyl/butyryl cholinesterase
• This improves cognitive functions like memory
and awareness
• Side effects are mostly nausea and vomiting and
at low doses it is generally safe
• It can sometimes dangerously slow heartbeat in
which case atropine (Ach blocker) is used
11. Which is more hydrophillic or less lipophillic ?
How does brain get glucose from blood
when glucose is not lipophillic at all?
12. Dopamine precursor
• External DA can’t cross BBB but the prodrug L-
dopa can. L-Dopa is dopamine with acid group to
create an amino acid functional group. The blood
brain barrier has Amino Acid Transporter which
allows penetration of L-dopa, even though L-
Dopa is less lipophillic than DA
• In the brain it gets metabolized into dopamine by
the enzyme DOPA decarboxylase.
• Thus, L-DOPA is used to increase dopamine
concentrations in the brain which is lowered in
Parkinson
13.
14. • It is most preferred and safest drug in
Parkinson
• Metabolism outside the brain can lower the
efficacy of L-Dopa
• Thus L-Dopa is given with carbidopa which
blocks Dopamine decarboxylase mediated
peripheral metabolism and allows high dose
of L-Dopa to penetrate brain. Carbidopa itself
doesn’t penetrate the brain.
15.
16. Carbidopa
• It is a Dopamine decarboxylase inhibitors.
• It’s purpose is to increase efficacy of L-Dopa
by preventing it’s peripheral metabolic
degradation and thus allowing more L-Dopa
to penetrate the brain
• While Dopamine decarboxylase exists both
inside and outside the brain, Carbidopa only
blocks metabolism outside the brain cause it
can’t penetrate the brain.
17. Entacapone
• It is a Catechol-O-methyl Tranferase (COMT)
inhibitors
• Entacapone prevents COMT from
metabolizing L-DOPA into inactive metabolite
3-methoxy-4-hydroxy-L-phenylalanine
(3-OMD) in the periphery.
• Thus more L-Dopa can penetrate the brain
• It itself doesn’t cross BBB
18. Amatidine
• It promotes Dopamine release and prevents
reuptake of dopamine in the CNS
• Exact MOA is not known. It promotes dopamine,
noradrenaline and serotonine and blocks
monoamine oxidase A and NMDA receptors,
• It has amine group with pKa of 10.8. Although
mostly protonated in the blood, the unique cage
structure provides a very high lipophilicity for
good penetration into brain and also prevents
metabolism such that it is excreted from kidney in
unchanged form
22. Review
• In Parkinson neurons that make Dopamine die
• Thus need to supplement dopamine externally
• But Dopamine can’t penetrate the brain (body
makes dopamine in brain itself)
• Thus given in prodrug form- levodopa
23. • Dopamine used for motor functions
• Acetylcholine used for motor and cognitive
functions
• A balance of DA and Ach is needed for proper
movement
24. • Levodopa has an amino group and penetrate
the brain utilizing the amino acid transporters
in the BBB
• After getting inside brain, it is metabolized
into dopa which eventually forms dopamine
• This is a good strategy but it has metabolic
problem
25. • There are 3 enzymes that want to degrade the
levodopa outside brain thus limiting it’s
therapy
They are
• Dopamine decarboxylase
• COMT
• MOA (mono amine oxidase)-B
26. • The solution is to co-administer Levodopa
with drugs that block those enzymes
• Dopamine decarboxylase- Carbidopa
• COMT - Entacapone
• MOA (mono amine oxidase)-B :Selegiline
• Thus more Levodapa can enter the brain
27. Acetylcholine based therapy are also useful
• 1) AntiCholinergics: lower Ach levels prevent tremors
(as balance is reached with preexisting lowered DA lvls)
• 2) Cholinergics: Increasing Ach levels controls dementia
• (Lowering Ach levels might have lead to dementia as
Ach is needed for cognitive function. Thus better to go
with levodopa based therapy)
• Dementia is a cognitive (thinking capacity)defect which
sometimes (not always)occurs in Parkinson at later
stage
28. Especial Topic
Deep Brain Stimulation
A drugless therapeutic wonder for
Parkinson, Alzheimer, Depression and
Dystonia
29. • Imagine curing UNCURABLE DISEASES not with
drugs but just a piece of lead rod nailed into your
brain! (remember brain feels no pain as it has no
pain receptors)
• The lead rod insulated except at the tip and
delivers electrical stimulation to only a targeted
area in brain
• It doesn’t shock the patient or harm other brain
areas
• DBS is FDA approved for Parkinson and in Phase 3
clinical trial for Alzheimer
30.
31. Incredible outcome in Parkinson and Dystonia
Youtube- Andres Lozano- Parkinson's, depression and the switch that might turn them off