Zalfa Hibatullah R.

A
155070500111024
Farmasi B

1. A 56-year-old man with advanced PD continues to have severe unpredictable “off” periods that
cause significant impairment. His home drugs include carbidopa/ levodopa/entacapone
18.75/75/200 mg 1 tablet four times daily, rasagiline 1 mg by mouth daily, ropinirole 1 mg by
mouth three times daily, ondansetron 4 mg by mouth every 8 hours as needed for nausea, and
atropine eyedrops 2 drops by mouth at bedtime for drooling. Which one of the following would
be best to discontinue when initiating the rescue medication apomorphine subcutaneous
injection for this patient?

A. Rasagiline.

B. Ropinirole.

C. Atropine.

D. Ondansetron.

Jawab: D. Ondansentron

Apomorphine adalah terapi untuk off period yang mekanisme kerjanya yaitu agonis reseptor
dopamin non selektif. Apomorphine tidak boleh digunakan bersamaan dengan obat antagonis
reseptor serotonin seperti ondansetron karena akan dapat mengakibatkan hipotensi parah, sehingga
pada pasien tersebut terapi ondansetron harus dihentikan terlebih dahulu sebelum diberikan injeksi
subkutan apomorphine.

2. A 45-year-old man presents to your outpatient clinic with bilateral tremor in his hands. The
tremor is of low amplitude and rapid frequency. This has become impairing to his career as an
electrician. Other neurologic symptoms are absent. Which one of the following is most helpful
in confirming this patient’s essential tremor (ET)?

A. Improvement with smoking cigarettes.

B. Worsening with smoking cigarettes.

C. Improvement with alcohol intake.

D. Worsening with alcohol intake.

Jawab: C. Membaik dengan intake alkohol

Jenis tremor yang dialami pasien ET yaitu action tremor lebih sering daripada rest tremor, tremor
bilateral, amplitudo tremor rendah dan frekuensinya cepat. Indikator lain pada pasien dengan ET
adalah terjai perbaikan gejala apabila pasien meminum alkohol, sedangkan pada tremor Parkinson
tidak terjadi perubahan dengan meminum alkohol.
3. A 67-year-old man has symptoms of bilateral upper extremity resting tremor and moderate
rigidity of limbs. His current drugs include metformin 1000 mg twice daily and metoclopramide
5 mg with meals. Which one of the following would most likely indicate PD rather than ET or
pseudoparkinsonism in this patient?

A. Olfactory dysfunction.

B. Metoclopramide treatment.

C. Improvement with primidone.

D. Advanced age of onset.

Jawab: D. Usia pasien yang sudah lanjut

4. A patient presents with an onset of rigidity and bradykinesia over 48 hours. Her home drugs
include lisinopril 20 mg daily, simvastatin 40 mg every night at bedtime, and risperidone 3 mg
twice daily. Which one of the following is this patient most likely experiencing?

A. PD.

B. ET.

C. Pseudoparkinsonism.

D. Tardive dyskinesia (TD).

Jawab: C. Pseudoparkisonism

Pasien mendapatkan terapi risperidone 3 mg sehari dua kali. Obat ini merupakan obat antipsikotik.
Obat antipsikotik bekerja pada reseptor dopamin di otak. Maka, pasien yang mendapatkan terapi
antipsikotik beresiko terkena gejala ekstrapiramidal seperti parkisonism. Parkinsonism biasanya
muncul dalam hitungan hari atau minggu setelah dimulai terapi antipsikotik.

5. A patient presents with the following regimen: carbidopa/levodopa 25/100 mg 2 tablets three
times daily, amantadine 100 mg daily, and pramipexole 1 mg daily. Which one of this patient’s
nonmotor symptoms is least likely to respond to dopaminergic medications?

A. Muscle pain.

B. Micrographia.

C. Constipation.

D. Depression.

Jawab: C. Konstipasi
6. A 68-year-old woman has PD managed with the following drugs: carbidopa/levodopa 25/100
mg four times daily, rasagiline 1 mg daily, atorvastatin 10 mg daily, polyethylene glycol 17 g
daily, and chlorthalidone 50 mg daily. Her most prominent PD symptoms/complications include
wearing off nearing the time of her next dose of carbidopa/levodopa and bilateral resting
tremor of her upper extremities. She has no edema or hypertensive blood pressure readings.
She is currently experiencing orthostasis and has fallen a few times in the past week. Which one
of the following would best treat this patient’s postural instability?

A. Decrease the dose of carbidopa/levodopa.

B. Decrease the dose of rasagiline.

C. Add fludrocortisone.

D. Decrease the dose of chlorthalidone.

Jawab: D. Mengurangi dosis chlorthalidone

Untuk mengurangi ketidakstabilan postural yang dialami pasien dapat dilakukan pengurangan dosis
chlorthalidone. Chlortalidone adalah obat diuretik untuk terapi hipertensi dan edema. Orthostasis
yang dialami pasien kemungkinan disebabkan karena obat antihipertensi yang dikonsumsi
menyebabkan pasien mengalami hipotensi. Pasien tidak mengalami gejala edema maupun
hipertensi, jadi obat ini tidak sesuai untuk pasien. Sehingga untuk mengatasi hal tersebut dosis obat
hipertensi dihentikan.

7. A 72-year-old female patient is in the clinic for assessment after a fall 1 week ago. She was seen
in the emergency department at that time, but no significant injuries were noted. She states
that she was dizzy before her fall. She has a history of hypertension, PD, and osteoarthritis. Her
current medications include hydrochlorothiazide 25 mg/day, metoprolol XL (extended release)
50 mg/day, lisinopril 10 mg/day, tramadol 50 mg three times daily as needed for pain,
levodopa/carbidopa CR (controlled release) 200/50 mg twice daily, and pramipexole 0.125 mg
twice daily. She states that her PD symptoms are much better controlled since adding
pramipexole and decreasing levodopa/carbidopa 1 month ago. On physical examination, blood
pressure is 136/72 mm Hg, with a heart rate of 60 beats/minute sitting, and 118/60 mm Hg,
with a heart rate of 62 beats/minute standing. Her gait looks good, and her strength is good.
Which is the most appropriate recommendation to reduce her risk of future falls?

A. Discontinue pramipexole.

B. Decrease metoprolol dose.

C. Add midodrine.

D. Add fludrocortisone.

Jawab: B. Mengurangi dosis metoprolol

Tekanan darah pasien sudah termasuk normal untuk usia 72 tahun, jadi hipertensi pasien dapat
dibilang sudah teratasi. 72 tahun TD nya boleh sampai 150/90 mmHg. Obat antihipertensi yang
dikonsumsi pasien yaitu hidroklorotiazid, metoprolol, dan lisinopril apabila digunakan bersamaan
dapat menyebabkan hipotensi dan pasien terjatuh. Sehingga untuk mengurangi resiko pasien
terjatuh, dosis salah satu obat antihipertensi yaitu metoprolol dapat dikurangi.

Yang menyebabkan hipotensi ortostatik adalah diuretik yaitu hidroklorotiazid dan ACE inhibitor.

Beta blocker bukan pilihan pertama untuk pasien hipertensi

Fludrocortison harus dimpnitoring jangan sampe hipertensi

8. R.M. is a 55-year-old man who has received a diagnosis of PD. At this time, his symptoms are
mild but slightly embarrassing, consisting primarily of mild bradykinesia and impaired dexterity,
most notably with micrographia. Minimal tremor is present. R.M. asks to be initiated on
treatment.

Which one of the following is best to recommend for R.M.?

A. Carbidopa/levodopa 25/100 mg three times daily.

B. Bromocriptine 1.25 mg daily.

C. Benztropine 1 mg twice daily.

D. Rasagiline 1 mg daily.

Jawab: D. Rasagiline 1 mg per hari

9. Four years later, R.M. has continued to receive treatment by the movement disorder clinic, but
his illness has progressed. He now has worsened bradykinesia and muscle stiffness. He is
currently taking ropinirole 6 mg three times daily. Which one of the following is best to
recommend for R.M.?

A. Add amantadine 100 mg daily and continue ropinirole.

B. Switch to carbidopa/levodopa 25/100 mg three times daily.

C. Switch to apomorphine 2 mg daily.

D. Add entacapone 200 mg daily and decrease ropinirole.

Jawab: B. Ganti ke carbidopa/levodopa 25/100 mg sehari tiga kali

Gejala yang dialami pasien setelah 4 tahun semakin parah sehingga obat harus diganti. Kombinasi
carbidopa/levodopa dapat mengatasi gangguan motorik dengan lebih baik daripada obat golongan
agonis dopamin yaitu ropinirole.

10. A 58-year-old man is referred to you after a new diagnosis of early-onset PD. His symptoms are
still mild and consist of right hand tremor, bradykinesia, and muscle stiffness. Which one of the
following education points is the best to provide this patient?

A. He should start carbidopa/levodopa.

B. Long-acting medications prevent adverse effects.

C. Consumption of coffee will delay progression.

D. Delaying the start of carbidopa/levodopa is prudent.

Jawab: D. Menunda mulai terapi carbidopa/levodopa

Karena pasien berusia <65 tahun dan gejala yang dialami masih termasuk ringan, maka terapi
carbidopa/levodopa dapat ditunda terlebih dahulu. Untuk terapi awal dapat diberikan obat golongan
agonis dopamin.

11. An 86-year-old woman with PD arrives for her yearly checkup. She is currently treated with
carbidopa/levodopa 25/100 mg 2 tablets three times daily. Her symptoms are well enough
controlled that she can function independently, and she has had no falls. However, she has
postural instability because of her dyskinesias. Reducing her carbidopa/levodopa dose was
previously unsuccessful because her rigidity and bradykinesia increased. At this visit, the
physician adds pramipexole 0.125 mg three times daily to optimize symptom improvement.
Which one of the following factors would best optimize this patient’s treatment when
pramipexole is added?

A. Increase carbidopa/levodopa.

B. Stop carbidopa/levodopa.

C. Decrease carbidopa/levodopa.

D. Add rasagiline.

Jawab: D. Menambah rasagiline

Untuk meningkatkan terapi pasien dapat ditambah rasagiline bersamaan dengan pramipexole.
Pasien masih mengalami gejala dyskinesia akibat dosis levodopa terlalu tinggi, sehingga dosis
levodopa sebaiknya tidak ditingkatkan lagi. Dan apabila dosis carbidopa/levodopa diturunkan, pasien
mengalami kaku otot dan bradykinesia meningkat. Sehingga sebaiknya dosis carbidopa/levodopa
tetap yaitu 25/100 mg sehari tiga kali dua tablet, dan ditambah pramipexole 0,125 mg sehari tiga kali
dan rasagiline untuk mengatasi gejala pasien.

12. A 56-year-old man with advanced PD continues to have severe unpredictable “off” periods that
cause significant impairment. His home drugs include carbidopa/levodopa/entacapone
18.75/75/200 mg 1 tablet four times daily, rasagiline 1 mg by mouth daily, ropinirole 1 mg by
mouth three times daily, ondansetron 4 mg by mouth every 8 hours as needed for nausea, and
atropine eye drops 2 drops by mouth at bedtime for drooling. Which one of the following would
be best to discontinue when initiating the rescue medication apomorphine subcutaneous
injection for this patient?

A. Rasagiline.

B. Ropinirole.

C. Atropine.

D. Ondansetron.

Jawab: D. Ondansetron

Apomorphine adalah terapi untuk off period yang mekanisme kerjanya yaitu agonis reseptor
dopamin non selektif. Apomorphine tidak boleh digunakan bersamaan dengan obat antagonis
reseptor serotonin seperti ondansetron karena akan dapat mengakibatkan hipotensi parah, sehingga
pada pasien tersebut terapi ondansetron harus dihentikan terlebih dahulu sebelum diberikan injeksi
subkutan apomorphine.

13. Q.T. is a 70-year-old man with a 9-year history of Parkinson disease (PD). He comes to the clinic
today with impairing “on-and-off” periods that occur at least once per day, often at
unpredictable times. Q.T.’s drug regimen is as follows: carbidopa/levodopa 25/250 mg CR 1
tablet four times daily (3 years), pramipexole 1 mg three times daily (1 year), and entacapone
200 mg four times daily (2 years).

Which one of the following would best improve Q.T.’s on-and-off periods?

A. Add apomorphine 2 mg as needed during “off” period. + antiemetik trimetobenzamid dimulai 3

hari sebelum pemberian apomorphine 3-12 mg per hari dan dilanjutkan hingga 2 bulan cari
pemakaian trimetobenzamid

B. Increase entacapone to 200 mg five times daily. -> entacapone memperbaiki enzim supaya tidak
terjadi degradasi ......

C. Increase carbidopa/levodopa to 25/250 mg 4 tablets four times daily.

D. Change from pramipexole to ropinirole.

Jawab: A. Ditambah apomorphine 2 mg saat terjadi gejala “off”

Apomorphine adalah terapi untuk off period yang mekanisme kerjanya yaitu agonis reseptor
dopamin non selektif. Obat ini efektif untuk mengatasi gejala off yang dialami pasien.
14. Two years later, Q.T.’s illness has progressed as expected. He is now experiencing dyskinesias of
the upper extremities and significant postural instability, which impair his ability to complete
activities of daily living independently. Which one of the following is most likely to prevent Q.T.
from undergoing deep brain stimulation?

A. Advanced age.

B. Length of carbidopa/levodopa treatment.

C. Apomorphine treatment.

D. Onset of PD dementia.

Jawab:

15.

Jawab: D. Penghentian terapi metoklopramid untuk mengetahui apakah gejala yang dialami pasien
merupakan drug-induced parkinsonism atau bukan

Metokloperamid merupakan salah satu obat yang dapat menginduksi gejala parkinsonism. Gejala ini
dapat sembuh dengan sendirinya setelah penghentian metokloperamid. Apabila gejala parkinsonism
yang dialami pasien hilang setelah penghentian obat metokloperamid, maka pasien positif
mengalami Drug-induced Parkinsonis. Namun apabila setelah metokloperamid dihentikan masih
timbul gejala, maka kemungkinan pasien menderita parkinson.
16.

Jawab: A. Haloperidol dihentikan dan diganti dengan quetiapine

Haloperidol merupakan obat neuroleptics yang dapat menyebabkan drug-induced parkinsonism dan
dapat memperparah Parkinson Disease yang dialami pasien. Maka dari itu, terapi haloperidol
dihentikan dan diganti dengan quetiapine. Karena quetiapine merupakan obat antipsikotik atipikal
yang beresiko rendah untuk pasien PD dan aman untuk pasien lansia.

17.

Jawab: C. Pramipexole

Untuk pasien < 65 tahun dengan gangguan motorik dapat diberikan agonis dopamin sebagai terapi
awal dan untuk mengurangi gangguan fungsional yang disebabkan carbidopa/levodopa
Rasagiline diberikan untuk pasien yang masih mengalami gejala Parkinson ringan. Dosis Rasagiline
yaitu 0,5 mg sehari sekali dan ditingkatkan 1 mg sehari sekali
18.

Jawab:

Citalopram -> selective

serotonin reuptake inhibitor,
harus dihindari untuk pasien
PD yang menerima terapi
MAOB (rasagiline) karena
terjadi interaksi

Amitriptyline -> obat

antidepresan trisiklik

Ci

19.

Jawab: D. Ropinirole

Ropinirole mengakibatkan efek samping somnolence yaitu rasa kantuk berat saat melakukan
aktivitas sehari-hari

20.
Jawab: C. Pramipexole
21.

Jawab: B. Carbidopa/levodopa
22.
Jawab: B. Carbidopa/levodopa
23.

Jawab:

Disesuaikan dengan
waktu titrasi obat. Dicari
obat yang titrasinya cepat
karena dia mau kerja ke
luar negeri, bisa
mengatasi gejala, dilihat
efek samping.

24.
25.

26.
27.

28. A 66-year-old man with a diagnosis of PD is being examined today in the clinic. He has been
taking levodopa/ carbidopa for 6 years. His current levodopa/carbidopa dose is 100/25 mg, 1½
tablets in the morning, 1 tablet at 11 a.m., 1 tablet at 2 p.m., 1 tablet at 5 p.m., and ½ tablet at 8
p.m. He has been experiencing motor complications for about 3 months, including on-off
symptoms and freezing episodes. On physical examination, he has some weakness, gait and
balance abnormalities, and rigidity. His ability to ambulate and perform self-care activities
during the past 3 months has continued to decline. Which is the most appropriate
recommendation for this man’s symptoms?

A. Add benztropine to levodopa/carbidopa.

B. Decrease the levodopa/carbidopa dose to 4 tablets daily.

C. Switch to levodopa/carbidopa CR.

D. Add entacapone to levodopa/carbidopa.

29. The 66-year-old patient in the previous question returns to the clinic 2 weeks after your
recommendation above. He states that, overall, he thinks he is doing better, but that he often
feels nauseated and occasionally feels light-headed or dizzy. He also describes some abnormal
movements, which are identified as dyskinesias on physical examination. He also states that he
has experienced hallucinations on two occasions, which was rather disturbing to him. Which is
the most appropriate recommendation for this man?

A. Add prochlorperazine for nausea.

B. Decrease the daily dose of levodopa/carbidopa.

C. Initiate rasagiline therapy.

D. Initiate ropinirole therapy.

30. T.B. is a 63-year-old man who received a diagnosis of early PD about 6 months ago but who is
otherwise healthy. He did not receive treatment with any medications when his PD was first
diagnosed, but on the advice of his physician he started therapy with selegiline 5 mg twice daily
about 4 weeks ago. He is in the clinic today because of difficulty sleeping and difficulty with his
memory. He states that, on most days, he feels tired but just cannot fall asleep. He states that
his wife has a prescription for lorazepam 0.5 mg and that he has taken one tablet when he has
had difficulty sleeping. He is asking for a prescription for lorazepam to help him sleep. Which is
the best recommendation for this patient?

A. Give him a prescription for lorazepam 0.5 mg at bedtime.

B. Have him take diphenhydramine 50 mg at bedtime.

C. Change the selegiline dosing from twice daily to morning and noon.

D. Add levodopa/carbidopa to selegiline.

31. A 68-year-old woman with PD has been taking levodopa/carbidopa 100/25 mg four times daily
for 2 weeks. Previously, she was taking levodopa/carbidopa 100/25 mg three times daily. She is
calling your clinic to see what she can do about the symptoms she describes, which include
nausea, light-headedness, and involuntary movements, which sound like dyskinesias. Her PD
symptoms were fairly well controlled on the three-times-daily schedule, but her physician
increased the dose to four times daily to achieve additional benefit. Which is the best
recommendation to address this woman’s symptoms?

A. Add rasagiline.

B. Decrease the levodopa/carbidopa dose to 100/25 mg three times daily.

C. Add ropinirole.

D. Change the levodopa/carbidopa dose to 100/10 mg four times daily.

32. W.S. is a 57-year-old man initiated on rasagiline for treatment of his newly diagnosed Parkinson
disease. He develops a cough, body aches, and nasal congestion. Which medication is best to
treat W.S.’s symptoms?

A. Guaifenesin.

B. Dextromethorphan. -> interaksi dgn Rasagilin, menyebabkan psikosis

B. Tramadol. -> interaksi dgn Rasagilin, menyebabkan kejang

C. Pseudoephedrine. -> interaksi dgn Rasagilin, menyebabkan hipertensi

Jawab: A. Guafenesin

33. Obat agonis dopamin menyebabkan hipotensi ortostatik. Maka untuk terapinya ditambah
fludrocortison

Tremor aja kasih antikolinergik -> diphenhydramine, tri

Amatadin hanya untuk dyskinesia

Kalo tremor, bradikinesia parah dikasih levodopa, carbadopa, entecapone

Wearing off -> frekuensi ditambah, dosis tetap dulu. Kalo dosis langsung ditinggikan bisa
menyebabkan efek samping diskinesia

komplikasi hipotensi ortostatik tidak selalu dicover, bisa pake non farmakologi aja. Hipotensi bisa
juga karena hipovolemik karena cairan banyak yang keluar
 Zalfa Hibatullah R. A
155070500111024
Farmasi B
L.M., a 55-year-old, right-handed male artist, presents to the neurology clinic complaining of
difficulty painting because of unsteadiness in his right hand. He also complains of increasing
difficulty getting out of chairs and tightness in his arms and legs.

His wife claims that he has become more "forgetful" lately, and L.M. admits that his memory does
not seem to be as sharp.

His medical history is significant for depression for the past year, gout (currently requiring no
treatment), constipation, benign prostatic hypertrophy, and aortic stenosis.

On physical examination, L.M. is noted to be a well-developed, well-nourished man who displays a

notable lack of normal changes in facial expression and speaks in a soft, monotone voice. A strong
body odor is noted. Examination of his extremities was slight "ratchetlike" rigidity in both arms and
legs, and a mild resting tremor is present in his right hand. His gait is slow, but otherwise normal,
with a slightly bent posture. His balance is determined to be normal , with no retropulsionor loss of
righting reflexesafter physical threat. His genitourinary is only remarkable for enlargement of
prostate. The remainder physical examination of LM and laboratory findings are normal.

• What signs and symptomssuggestive of PD present in LM?

• Which of symptoms are of classic symptoms for diagnosing PD and which are considered
“associated”symptoms?
• How should LM be treated for PD and associated symptoms?
• In what stage of the disease is LM?
• Should therapy be initited with a dopamine agonist or levodopa?
• LM is to be started on dopamine agonist. Which agent should be selected?
• What is the most effective way to dose pramipexole or ropinirole?
• What are the adverse effects of pramipexole and ropinirole? How can these be managed?
• When to begin levodopa?
• What are the advantages and disadvantages of Sinemet over levodopa alone?
• How is Sinemet dosed? Before, with or after meals?
• When should entacapone (COMT inhibitor) be initiated? How is it dosed?