Penyakit Parkinson Fix!1

8/18/2019 Penyakit Parkinson Fix!1

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dr. H.M. Luthf, Sp. SLab./SMF Neurologi

Fakultas Kedokteran UNMULSamarinda





PENDAHULUAN

Sejarah : PENYAKIT PARKINSON PP!:"ames Parkinson #$#% Para&isis A'itans"ean (artin )har*hot #$%+ Peny, ParkinsonTretiakoff #+#+- .reenfie&/- 0osan12et #+34

Lesi s25stansia ni'ra SN!0ein- )ar&sson- 0ar5e2- Hornykie6ien7- #+89 )ort7ias#+8% Do amine DA! ; Le<o/o a(PTP Ne2roto=in SN DAS ee&man an/ 0os*h #++$ s2r'i*a& inter<entions



KLASIFIKASI

#, Primer ata2 i/io atik Penyebab tidak diketahuiSebagian besar kasus penyakit ParkinsonAda peran toksin asal lingkungan

9, Sek2n/er ; Simtomatis ata2 ak2isitaInfeksi penyakit atau zatSlow Virus = pasca encefalitis letargica

Toxic kronis !TPT" !n" #$" !g" #S%" #&Trauma = Petin'u (Pugilistic )ncephalopathia*Sepakbola+ain hipoparatiroid" ,ipothyroid" !ulti infark" -egen",epatoserebral



KLASIFIKASI

$bat = -rug Indiced Parkinsonism Antipsikotik : CPZ, proklorperazin, haloperidolAntiemek metoklopramid, Etanol, Metanol, Reserpin,Lithium, Tetrabezene, Fenotiazin, Butiro enon,Al ametildopa, dialtiazem, !erapamil, "aptopril,!inkristin, !alproat, enitoin, sitosin # arabinosa,putus alkohol



KLASI>IKASI

./ Sindroma parkinson plus0!ultiple Systemdegenerasi

$e%ala parkinson & kelainan neurolo'is lainPro'resi (upranu"lear Pals)Atropi mult) sistem : *e'en, (etrioni'ral, (h)+*ra'er, *e'en-li!o # Pontoserebellar, (indroma Parkinson # Amiotropi*e'en $an'lionik # .ortikobasal

(indroma *emensia : + (indroma .onplek # Parkinsoonism #*emensia .omplek # AL( /$uam0, Pen) Le1) Bod) *i us,Creutz eldt # 2a"ob, bersamaan pen)akit Alzheimer3erediter : 4ilson, 3aller!erdon # (patz, 3untin'ton5euroa"anthosis, Ma"hado # 2oseph, Luba'



KLINIS PENYAKIT PARKINSON

TRIAS PARKINSON

1. !"M#!$. %K&N"S&%'. !&(&)& %S

Hilang REFLEX POSTURAL“FREEZING”




1. TREMOR :

Rest Tremor / Saat IstirahatMenin !at saat EmosiMen hi"an saat !er#aTan an $ #ari men hit%n %anKa!i & m%"%t




'. AKINESIA / (RADIKINESIA :) S%"it mem%"ai era!an )Lam*an) S%"it *erhenti

+A,AH : a. M%!a to-en *. Ti a! a a e -resi 0. Ke i-an mata #aran,ALAN : a. Lan !ah !e0i"

*. Ti a! a a "am*aian 0. S%"it mem%tar *a"i!

(I ARA : a. Monoton& "am*an *. Tan-a La % s%ara



REFLEX POSTURAL HILANG :

LAIN2 GEJALA :

Tulisan “ Micrograa” Bicara Monotoon tanpa lagu bicara Reek Postural hilang Saat berdiri bila di DORONG TIDAK ADA reaksi / REFLEX sikap

Retropulsion TESLateropulsion TES

Antepulsion TES “Drolling Salivation” = Ngiler



2. 3e#a"a A4a" Pen5. Par!inson:

#$4 P? @Tremor 1'6 78&9Ri i itas / A!inesia 2 16&7K%ran tram-i" / ; s%"it t%"is ' 1'&23an %an ,a"an '1 11&9

N5eri oto& ram- otot& < A0hin = 19 >&'3an %an Psi!iatri > ?&?3an %an (i0ara 7 &>Ke"emahan %m%m@Fati %eB 9 '&7

N i"er 1&2,a"an tan-a "am*aian 1&2M%!a to-en 1&2D5s-ha ia 1 8&9Parestesia 1 8&9



'. DDC TREMOR PARKINSON:

1. Se!%n er Par!insonism:Infeksi penyakit atau zat

Slow Virus = Pasca Encefalitis letargica Toxic : KRONIS MPTP, Mn, CO, Mg, CS2, CN Trauma = Petinju (Pugilistic Encephalopathi)

Sepakbola

Lain : hipoparatiroid, hipothyroid, Multi infark,Degen. Hepatoserebral,Drug Induced Parkinsonism

'. Par!insonism P"%s @M%"ti Sistem De enerasiB



ORTI AL MOTOR AREAS

THALAMUS(ASAL

3AN3LIA

ERE(ELLUM

(RAINSTEM

SPINALORD



3AN3LIA (ASALIS

Ters%s%n ari !e"om-o! inti:

1. Striat%m @neo;"im*i0 striat%mB Neostriat%m : P%tamen @P%tB ;

N%0". a% at%s @N B'. 3"o*%s Pa"i %s @3PeB ; 3PiB

. S%*stansia Ni ra @SNB?. S%*tha"ami0 N%0"e%s @STNB



NEUROTRANSMITTER DI 3(

Striat%m menerima INPUT ari :

Korte!s @3"%tamaterni!BS%*stantia Ni ra @Do-aminer i!B D1 ; D'Pen %!%"o-ontis @ ho"iner i!B

Striat%m men e"%ar!an OUTPUT !e:,a"%r ire0t @3a*aer i!B,a"%r in ire0t @3a*aer i! ; "%tamater i!B





Re*i ro*a& Inhi5ition STRIATU(



)IR)UIT 0ASAL .AN.LIA

THALA(O )ORTI)AL





"a&2r Dire*t B In/er*t DYSTONIA





Kadar DA, NA, ADR & DERAJATKEPARAHAN GEJALA PP

,%m"ah !as%s DA NA ADR

Tremor:Rin anSe an(erat

17''

'2>.' 1?8.2?8.> ''2.117.2 172.7

'19.1 >'.'1'>.? 188.8'9'.9 188.>

>>.9 188.862.6 > .2

188.? 188.?

Ri i itas:Rin anSe an(erat

12'

6 .9 1?9.>>.9 12 .8

'19.8 7?.1

''1.1 7 .2'12.1 11>.11' .2 '>.1

>1. >6.81'1.8 166.7

97.9 97.9

A!inesia:Rin an

(eratSe an

11>'

?71.1 111.'9>.9 67.7'19.8 7?.1

'?9.9 >1.216?.8 > .91' .2 '>.1

72.> >1.'117. 1'8.8

97.9 97.9

Ke!a!%an *er#a"anRin anSe an

(erat

19?

'

>2.6 191.29.2 19?.8

'19.8 7?.1

'91.6 2>.111>.1 21.?

1' .2 '>.1

18'.' 182.22'.2 78.

97.9 97.9



(ANA.E(EN P,PARKINSON :

Pen o*atan -harma0o"o is an o-erasi ti a !onse- %tama :Sim tomatik-

Unt%! mem-er*ai!i !e"%han e#a"a ; tan a'Protektif-

Unt%! mem-er*ai!i *er asar -ato isio"o is

Restoratif-Meran san -ert%m*%han se" *ar% an -ert%m*%han



O(AT'AN P.PARKINSON :

Do amine Pre*2rsor :G Le o o-a : (en era i e J Ma o-ar

ar*i o-a J Sinemet

Do amine A'onist : G (romo0r5-tin G Per o"i eG Lis%ri e G A-omor-hine G ar*e o"ineG Prami-e o"e G Re-iniro"eDo amine Re&easer : G Amanta ineAnti )ho&iner'i* : G Trihe 5-hene i"G (en tro-ineG Etho-ro-a ine G (i-eri ine G Pro050"i ineG 50rimineAnti Histamini*s : G Di-henh5 ramineG Or-hema ine G Phenin amine G h"or-heno amine



O(AT'AN P.PARKINSON :Inhibitor MAOB (Mono Amine Oxidase) :- Selegiline (Jumex)

Inhibitor COMT ( Catechol – O – Nethyl Transferase) : - Entacapone - Tolcapone

Anti Depressant : - Amitryptilin / Tri- Fluoxetine / SSRI

Muscle Relaxan : - Cyclobenzaprine- Diazepam

Anti Dopamine Perifer : - DomperidoneCholinergic Perifer: - Clozapine

Agonist glutamat : - Amantadine Anti Oksidan : - Vit E, Vit C, Beta carotene

Beta Blocker : - Propanolol



AL.ORITH( (ANA.E(ENT P,PARKINSON

# !

>2n*tiona&Im airment C

(e in S5m-tomati0/ Ne%ro-rote0ti e Thera-5

(e in Ne%ro-rote0ti e Thera-5 Antio i ants

Do-amine A onists Se"e i"ineTremor

Pre ominant



AL.ORITH( (ANA.E(ENT

P,PARKINSON 9 !

Amantan ineAnti0ho"iner i0s

A e 28 5ears A e 28 5ears

De-omine a onist om*ination @ o-amine a onist "o4G

ose "e o o-aB

onser ati e oses o "e o o-a@0onsi ers RB

Le o o-a@0onsi er RB

Amanta ine

Res onseto thera y



AL.ORITH( (ANA.E(ENT

P,PARKINSON 4 !3oo

Res-onsePoor or noRes-onse

<+earin $ O = D5s!inesia

Lo4est ose tomaintain s5m-tom

0ontro"

In0rease ose onsi er other

ia nosi OMT inhi*itor om*ination o-amine

a onist "e o o-a A "e o o-a Amantan ine Se"e i"ine Anti0ho"iner i0 Sma""er& more re %ent

osin Dietar5 a #%stments

@-roteinB S4it0h o-amine

a onist

De0rease "e o o-a ose

A or in0rease ose o o-amine a onist

S4it0h o-amine a onist

onsi er s%r er5



Dosis O*at PP :

Levodopa + Carbidopa 10/100, 25/100,25/250 mg per hari

Levodopa + Benserazid 50/100 mg per hari Trihexyphenidyl3 – 15 mg per hariSelegiline10 mg per hariBenztropine Mesylate1 – 8 mg per hariBiperiden3 – 6 mg per hariChlorphenoksamin 150-400 mg per hariCycrimine 5 – 20 mg per hariOrphenadrine 150-400 mg per hari



Dosis O*at PP :

(romo0ri-tin Mes5"ate 9 $ ?8 m -er hariPer o"i e Mes5"ate8.79 $ 9 m -er hari

a*er o"ine 8.9 $ 9 m -er hariPrami-e o"e 1.9 $ ?.9 m -er hariRo-iniro"e 8.79 $ '.? m -er hariPro050"i ine 7.9 $ 8 m -er hari

Etho-ro-ra ine 8 $ 28 m -er hariA-omor-hine 18 $ >8 m -er hariEnta0a-one '88 $ 1288 m -er hariTo"0a-one 88 $ 288 m -er hari



Dosis O*at PP :

As!or*i0 A0i @ itamine B 988 $ 1888 m -er hari(eta0arotene @Pro itamine AB ?888 IU m -er hari

Pro-rano"o" 18 $ 8 m -er hari



Tin/akan 0e/ah P, PARKINSON :

Thalamotomy

Thalamic Stimulation Pallidotomy Subthalamic Stimulation

Implamantasi Jaringan SN



L $ o-a Meta*o"isme



L $ o-a Pharma0o!ineti0





(otor *om &i*ations erio/

D5s!inesias

A. horei orm / < an0e "i!e= mo ements(. Other orms : D5stonia& M5o0"oni0& et0a%se *5 Le o o-a treatment: F"%0t%ations

G +earin $ o G On $ o -henomenon



Pro'ression of Parkinson /isease



Tin a!an Kom-"i!asi T PP :

3enera" strate ies1B Mo i 5 "e o o-a $ Fra0tionate ose

G S%staine re"ease'B A MAOG( inhi*itor $ se"e i"ine

B A OMT inhi*itor $ enta0a-one $ to"00a-one?B A a onist $ -er o"i e G *romo0ri-tine

G -rami-e o"e G ro-inero"e



DOPA /e*ar5o=y&ase DD)!

inhi5ition



OMT Inhi*ition



Penyakit Parkinson Fix!1

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