Parkinson

• Cracked open cogwheels: parkinsonism therapy

Lovodopa

• Bank vault threshold: blood brain barrier (BBB)

• "L" rope crank inside vault: levodopa (L-DOPA) crosses the BB

• Unfurled/untangled rope in vault: levodopa is converted to dopamine by DOPA decarboxylase in the CNS

• Unfurled rope in lobby: levodopa is converted to dopamine by DOPA decarboxylase in the periphery (can't cross BBB)

• Nauseated hostage: levodopa can cause GI distress (due to peripheral conversion into dopamine). Vomiting from triggering of peripheral chemoreceptors

• Arrhythmia rope: levodopa can cause cardiac arrhythmias (due to peripheral conversion into dopamine) (tachy, afib, Ventricular asystole)

• Passed out hostage: levodopa can cause orthostatic hypotension (due to peripheral conversion into dopamine)

• Psychiatrically disturbed hostage: levodopa can cause neuropsychiatric symptoms e.g. anxiety, agitation, insomnia, confusion, hallucination (due to excess dopamine in the CNS)

• End of rope wearing-off: chronic levodopa therapy can cause a wearing-off reaction (akinesia and dyskinesia re-emerge at the end of each dose)

• "Too long!": chronic levodopa therapy can cause response fluctuations (wearing-off reaction, on-off phenomenon) and dyskinesias

• Flashing on and off: chronic levodopa therapy can cause an on-off phenomenon (periods of akinesia alternate with periods of improved mobility, not related to dose) (episodes of restrictive mobility in hours)

• Narrowing window/watch: the therapeutic window of levodopa therapy narrows as Parkinson's progresses (unpredictable response to therapy). Too much dopamine: dyskinesia. Not enough dopamine: bradykinesia and regidity

• Writhing sneeze: chronic levodopa therapy can cause dyskinesias (choreoathetosis of the face and distal extremities) (involuntary twisting of face and extremities)

• Damaged psychotic painting: levodopa is contraindicated in psychotic patients (blocking CNS dopamine)

Carbidopa

• Police car on periphery distracting: carbidopa (peripheral DOPA decarboxylase inhibitor) (cannot cross BBB)

• Scared into vault: carbidopa increases the bioavailability of levodopa (prevents peripheral conversion into dopamine)

• Pulling away from hostages: carbidopa decreases peripheral side effects of levodopa therapy (but exacerbates neuropsychiatric side effects)

COMT inhibitors

• InTerCOM guard shooting "L" crank: catechol-O-methyltransferase (COMT) converts levodopa to 3-O-methyldopa (3-OMD) in the periphery

• Tall Al Capone gangster: tolcapone (a peripheral and central COMT inhibitor) increases the bioavailability of levodopa

• Al Capone gangster at entrance: entacapone (a peripheral COMT inhibitor) increases the bioavailability of levodopa

• InTerCOM guard in vault: catechol-O-methyltransferase (COMT) converts dopamine to 3-methoxytyramine (3-MT) in the CNS

• Tall gangster in vault: tolcapone (a peripheral and central COMT inhibitor) increases dopamine levels in CNS

• Hepatic gun: tolcapone can cause hepatic failure

MAO inhibitors

• Black mouse eating rope: monoamine oxidase B (MAO-B) selectively metabolizes dopamine

• Sledge hammer: selegiline (a selective MAO-B inhibitor) increases dopamine levels in the CNS

D Agonists

• Rope in a roll: ropinirole (D2 dopamine receptor agonists) is an important initial treatment of Parkinson's

• Double rope ladder: D2 dopamine receptor

• Big pecs: pramipexole (D3 dopamine receptor agonist) is an important initial treatment of Parkinson's

• Restless legs: dopamine receptor agonists (e.g. ropinirole, pramipexole) treat restless leg syndrome (RLS)

• "Rock and roll": dopamine receptor agonists (e.g. ropinirole) may enhance impulse control disorders (e.g. gambling, shopping, hypersexuality)

Amantaine

• Manatee: amantadine can treat some motor symptoms of Parkinson's (originally antiviral influenza agent)

• Breaking open rope: amantadine enhances the effect of endogenous dopamine (by increasing its synthesis/release and inhibiting its uptake)

Anti-M

• Tri-hex Benz car: trihexyphenidyl and benztropine (antimuscarinic agents used to treat parkinsonism) (unbalanced high levels of Ach)

• Trembling getaway car: trihexyphenidyl and benztropine (antimuscarinic agents) improve the tremor and rigidity of Parkinson's with no effect on bradykinesia