Side Effects Of Parkinson Medications

When Might I Be Prescribed An Anti

You should only be prescribed an anti-Parkinson’s drug if you have developed Parkinsonism symptoms as a side effect of your antipsychotic, and

• you can’t switch to a different antipsychotic or reduce your dose, or
• you have tried changing the antipsychotic or reducing the dose, but this has not helped your Parkinsonism symptoms.

These drugs should never be prescribed to prevent side effects that you havent already experienced.

What Medications Are Used To Treat Parkinson’s Symptoms

Since many of the motor symptoms of Parkinsons are the result of a lack of dopamine in the brain, most drugs used to treat Parkinsons are aimed at temporarily replenishing or imitating dopamine. The following list is a guide to medications approved by Health Canada to treat symptoms of Parkinsons1. Speak to your doctor for detailed information regarding effectiveness and side effects of a particular drug.

Levodopa

• Converted into dopamine in the brain and stored in nerve cells to replace depleted dopamine
• Combined with another drug, carbidopa or benzerazide, allows more levodopa to get to the brain and reduces side effects
• Helps improve muscle rigidity and movement
• Side effects include dyskinesias
• Over years of use, may be associated with wearing off

Dopamine Agonists

• Mimics or imitates action of dopamine
• Can be used as initial treatment or with levodopa in advanced stages
• Side effects include sleepiness, hallucinations, leg swelling and obsessions with food, sex and activities such as shopping, gambling and Internet use Amantadine
• Enhances dopamine release and blocks glutamate, a brain transmitter
• Used to treat early symptoms
• Can reduce dyskinesias and improve wearing off

Dopamine Agonist

COMT Inhibitors

Taking Sinemet With Food

Sinemet can be taken either with or without food. However, you should avoid taking Sinemet with foods that are high in protein. Some examples of high-protein foods are meat, eggs, or tofu.

Eating high-protein foods when you take your Sinemet dose may lengthen the time it takes for your body to absorb the drug. This delay means that your PD symptoms may not be reduced as quickly as usual after taking your dose.

Taking Sinemet while youre eating a diet high in protein may also decrease the total amount of levodopa that your body absorbs. This means that the drug may not work as well to treat your PD symptoms.

Talk with your doctor or pharmacist about when the best times are for you to take your Sinemet doses. They will be able to help you determine the best times, based on your other medications and your normal mealtimes.

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Dopaminergic Features And Their Treatment

Patients with PD usually present with features indicative of degeneration of nigrostriatal pathways. A useful clinical definition for PD is asymmetric onset of an akinetic rigid syndrome with resting tremor and a good response to levodopa. When applied by neurologists with an interest in movement disorders, this definition has a pathological correlation exceeding 98%. When treatment is considered appropriate, and this is a topic discussed in detail below, a variety of options is available. The use of dopaminergic drugs improves motor function, significantly reduces both the morbidity and mortality of PD, and improves quality of life.

Levodopa remains the drug most commonly used in PD. It is very effective in improving bradykinesia and rigidity, and in practice remains the gold standard against which other drugs are judged. Some studies, predominantly in vitro, have suggested that levodopa may be toxic. However, such data are conflicting, and some laboratory studies have suggested a growth factor-like effect for levodopa. Overall, the pre-clinical evidence for levodopa toxicity is not convincing and there are no data to indicate that any toxic action is of clinical relevance.

Table 1

Percentage of patients remaining on dopamine agonist monotherapy at years 14 and years 15 during treatment trials

Advantages Of Comt Inhibitors

When used with levodopa, COMT inhibitors can reduce the daily off time and increase the on time.

In many cases, the dose and frequency of levodopa can also be reduced.

The terms on/off or motor fluctuations refer to the period when people can no longer rely on the smooth and even symptom control that their drugs once gave them.

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Your Parkinsons Drug Treatment

Dopamine is a chemical messenger made in the brain. The symptoms of Parkinsons appear when dopamine levels become too low. This is because many of the cells in your brain that produce dopamine have died or are dying. Taking dopamine as a drug doesnt work because it cannot cross the blood brain barrier. To get around this, doctors use other medication that can act in a similar way.

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Medication Guidelines For Parkinsons Disease

There is no one best mix of Parkinsonâs medicines. You and your doctor will have to try a few treatment approaches to figure out the best one for you.

But there are some general guidelines for taking your medication. Be sure to ask your doctor or pharmacist for any specific tips for your treatment.

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Controlled Release Madopar And Sinemet

Controlled release preparations have the letters CR or HBS after the drug name.

These let the levodopa enter your body slowly instead of all at once. They can increase the time between doses.

They may be used when the dose of standard levodopa starts to wear off and the person taking it no longer feels the treatment is effective.

Controlled release options can sometimes reduce involuntary movements .

Parkinsons And Difficulty Eating

In the later stages of the disease, the muscles in your throat and mouth may work less efficiently. This can make chewing and swallowing difficult. It can also increase the likelihood of drooling or choking while eating.

Fear of choking and other eating problems may affect your nutrition. However, working with an occupational therapist or speech-language therapist may help you regain some control of your facial muscles.

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Ways To Cope With The Side Effects Of Parkinsons Disease Drugs

Prescription drugs are the most powerful tools modern science has available to help you fight your Parkinson’s disease symptoms but the very medications designed to make your life better can also cause side effects.

These side effects range from unpleasant to downright scary .

If you have Parkinson’s disease, you will already be familiar with the most frequently prescribed Parkinson’s disease medications:

• Levodopa works to boost your dopamine levels indirectly, and is almost always prescribed in combination with carbidopa. Brand names include Sinemet, Rytary, Parcopa, and Stalevo, and they’re powerful weapons in the fight against the motor symptoms of Parkinson’s disease.
• Dopamine agonists like pramipexole , ropinirole , apomorphine , and Neupro act similarly to dopamine, thereby reducing your Parkinson’s disease symptoms.
• COMT inhibitors, like entacapone , are prescribed to make levodopa work more effectively.
• MAO-B inhibitors help your brain use the dopamine it does have access to more efficiently, and examples are selegiline and rasagiline .
• Amantadine is both an anti-flu and Parkinson’s drug, and it is particularly useful in combating the involuntary movements levodopa can result in.

• Dyskinesia involuntary movements, which can strike the arms, legs, torso, and face
• Nausea and vomiting
• Diarrhea, constipation, and urinary difficulties, including discolored urine and finding it hard to pee
• Dizziness or lightheadedness

Monoamine Oxidase B Inhibitors

Other PD medications work by inhibiting the enzymes involved in dopamine metabolism, which preserves the levels of endogenous dopamine. One such class is the MAO-B inhibitors. As is discussed above, MAO-B is one of the main enzymes involved in the breakdown of dopamine, and reducing the activity of this enzyme therefore results in increased dopaminergic activity within the striatum, mediated by endogenous dopamine . Their use relieves motor symptoms in PD patients, and as with dopamine agonists they may be used as an initial treatment option, to delay the need for levodopa therapy, to reduce the risk of levodopa-induced motor complications . While they are sometimes sufficient for control of symptoms in early disease, most patients ultimately require levodopa-based treatment. MAO-B inhibitors may also be used in combination with levodopa-based preparations, to allow for a reduction in the levodopa dose.

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The Impact Of Drt Side Effects

The most impactful DRT side effects consist in dyskinesias, motor fluctuations and DDS. Common neurophysiopathological mechanisms involving the cortico-striatal plasticity link these motor and behavioral side effects .

Dyskinesias refer to a category of movement disorders that are characterized by involuntary muscle movements. They occur in more than half of PD patients after 510 years of L-DOPA treatment, with the percentage of affected patients increasing over time . They commonly present as chorea or choreoathetosis, though myoclonus, akathasia, ballism and other forms of abnormal movements. They lead to exhaustion, fatigue, risk of injury and weight loss causing pronounced discomfort and physical limitation. If dyskinesias becomes too severe impair the patients quality of life and a reduction in L-DOPA might be necessary.

Motor fluctuations, such as wearing-off and onoff effect, are approximately experienced by 40% after 46 years of treatment with L-DOPA, similar to the frequency of dyskinesias . Wearing off is the most common motor fluctuation seen in patients with PD. With this pattern, patients develop a predictable worsening of their parkinsonism at the end of the dose because of the short duration benefit after a given dose of L-DOPA. With disease progression the dosing response varies and patients may report a delayed-on or no-on . On-off fluctuations are characterized by sudden and unpredictable shifts between on and off state.

Are There Ways To Manage Dyskinesia

Once dyskinesia has started it is difficult to treat. However, there are several ways to delay it from starting or reduce it once it has begun.

Supplemental or alternative treatment options

Things you can do on your own

• Keep a diary that logs the time and frequency of dyskinesia, which will help your doctor assess if your medications are working and help you schedule daily activities when mobility is better.
• Physical activity, including mild aerobic exercise such as walking, dancing, and swimming, will help keep the body strong and prevent muscle weakening.
• Stress can make dyskinesia symptoms worse, so find ways to reduce stress and try to keep a positive attitude.
• Poor sleep at night is associated with dyskinesia. Aim for good sleep quality and try to experiment with different positions in bed that will help you relax and sleep better.

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Generic Vs Branded Drugs

Currently, there are multiple pharmaceutical companies that manufacture a generic formulation of carbidopa-levodopa, dopamine agonists, monoamine oxidase inhibitors, and anticholinergics. The U.S. Food and Drug Administration requires that generic drugs show a similar risk and benefit to the branded drug prior to market approval, but in rare cases this standard is not high enough.

A review supported by the Parkinsons Foundation reports evidence that if you are in more advanced stages of the disease, switching from branded drugs to generic, or from one generic to another, may have somewhat variable effects. The authors, including Parkinsons Foundation National Medical Advisor Michael S. Okun, MD, believe that the standards for approving generic drugs for PD may not be strict enough to demonstrate that the generic alternatives are equally effective.

Work with your doctor to develop a tailored treatment plan. Using generic drugs will likely provide a cost savings. Infrequently, a person living with PD may require brand medication.

If you make the switch, follow these tips:

• Report to your physician on the effectiveness of the drugs.
• Carefully keep a diary of any side effects.
• Record dose adjustments made by your physicians .
• Try to stay with a single drug manufacturer for your generic medications. You may need to ask your pharmacist to special order for you.

Dosage For Parkinsons Disease And Parkinsonism

Sinemet is approved to treat Parkinsons disease and certain cases of parkinsonism, which is a condition thats similar to PD.

For these uses, the recommended starting dosage of Sinemet is typically one tablet of 25 mg carbidopa / 100 mg levodopa, taken three times per day.

In some cases, your doctor may have you start taking one tablet of 10 mg carbidopa / 100 mg levodopa, three to four times per day. But this dose may not contain enough carbidopa to reduce your symptoms.

If your starting dosage of Sinemet doesnt reduce your symptoms, your doctor may have you add a tablet to one or more of your doses. For example, your doctor may recommend that you add a 25 mg carbidopa / 100 mg levodopa tablet or a 10 mg carbidopa / 100 mg levodopa tablet, either every day or every other day.

The maximum recommended daily dose of Sinemet is eight tablets of either:

• Sinemet 10 mg/ 100 mg, or
• Sinemet 25 mg / 100 mg

Regular dosing interval

Sinemet should be taken at a regular dosing interval. A dosing interval is how often you should take a medication so that its most effective. Your dosing interval depends on how many times per day youre taking the drug. Spacing out your doses with an even dosing interval helps keep the amount of Sinemet in your body consistent over time. This consistency can help reduce your symptoms.

Dosage when switching from levodopa

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Enhancing Healthcare Team Outcomes

While the initial treatment of a patient with Parkinson disease is by a neurologist, outpatient monitoring and continued care are often accomplished by the primary care provider or nurse practitioner/physician assistant these and other caregivers need to function as an interprofessional team when managing patients on levodopa therapy. When patients start on L-dopa, Frequent monitoring of BUN, creatinine levels, and hepatic function is necessary. Additionally, the patient must obtain a referral to the ophthalmologist for glaucoma screening. Patients on L dopa may develop mood changes and should be closely followed by a mental health nurse.

The primary care provider needs to know the Parkinson disease symptoms because L-dopa usually works for a short period, and patients may have to start on other medications. This situation is where ongoing monitoring by nursing can inform the clinician promptly of status changes so that additional interventions can commence. Also, the pharmacist should verify potential drug-drug interactions and dosing and consult with the clinician as more agents may be needed. Also, patients with Parkinson disease may develop a variety of autonomic symptoms and may need a referral to a gastroenterologist and urologist. Overall, there is no cure for Parkinson disease, and eventually, most patients succumb to the disorder, but interprofessional teamwork can optimize the outcome within these limitations.

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Mechanism Of Action Of Available Drugs

The major classes of drugs currently available for the treatment of idiopathic Parkinsons disease are shown in Table 1. Many aim to increase dopamine in the brain, by increasing its production or altering its metabolism .

Drugs with alter metabolism in boxed red italics

Levodopa

Levodopa is absorbed from the small intestine and transported into the brain where it is converted to dopamine. Levodopa has a short plasma half-life of about one hour. Early in Parkinsons disease, levodopa has a long duration of action which is independent of plasma concentration, but as the disease progresses, the duration of the effect reduces. The short-duration effect is strongly linked to plasma concentration and lasts, at most, hours.

Slow-release preparations are gradually absorbed, resulting in more sustained plasma concentrations. They have reduced bioavailability higher doses are required to match the benefit of an equivalent strength of a standard preparation. Rapid release preparations are taken in liquid form to enhance passage through the stomach and absorption from the small intestine.

Dopamine agonists

Apomorphine is a potent emetic so patients must be pre-treated with domperidone 20 mg three times daily orally for at least 48 hours before the first injection. Domperidone should be continued for at least a few weeks once regular intermittent treatment has commenced. The dose can then be tapered slowly as tolerance to the emetic effects of apomorphine usually develops.

Looking Out For Side Effects If You’re A Carer

If youre a carer of someone with Parkinsons, medication side effects can be difficult and tiring to cope with.

It may be that the person having side effects such as hallucinations and delusions or impulsive and compulsive behaviour does not realise they are experiencing them.

Its important to seek help from your specialist as soon as you can.

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Medication Guidelines For Parkinson’s Disease

There is no one best mix of Parkinsonâs medicines. You and your doctor will have to try a few treatment approaches to figure out the best one for you.

But there are some general guidelines for taking your medication. Be sure to ask your doctor or pharmacist for any specific tips for your treatment.

Constipation And Digestive Issues

As Parkinsons disease progresses, your digestive tract will slow down and function less efficiently. This lack of movement may lead to increased bowel irritability and constipation.

In addition, certain medications often prescribed for Parkinsons disease, such as anticholinergics, can cause constipation. Eating a balanced diet with plenty of vegetables, fruits, and whole grains is a good first step remedy.

Fresh produce and whole grains also contain a great deal of fiber, which can help prevent constipation. Fiber supplements and powders are also an option for those with Parkinsons.

Be sure to ask your doctor how to gradually add fiber powder to your diet. This will ensure you dont have too much too quickly and make constipation worse.

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