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by Carson-DeWitt R

Medications for Parkinson’s Disease

The information provided here is meant to give you a general idea about each of the medicines listed below. Only the most general side effects are included, so ask your doctor if you need to take any special precautions. Use each of these medicines only as recommended by your doctor and according to the instructions provided. If you have further questions about usage or side effects, contact your doctor.
Medicines for Parkinson’s disease work in a variety of different ways. The primary strategy is to increase the amount of dopamine or to activate the dopamine receptor, as it is the neurotransmitter pathway that is decreased in patients with Parkinson’s disease. Although most patients respond to medicines initially, the effects may wear off over time as the disease progresses. When a particular medicine stops working, your doctor may have to increase the dose, switch medicines, stop and then restart a medicine, or add on another medicine. In addition, many people experience disabling side effects (specifically, rapid “wearing-off” of the drug and abnormal movements, called dyskinesias) from long-term dopamine-replacement therapy, which requires a decrease in dose and possible substitution of another medicine or other form of therapy.

Prescription Medications

Levodopa
Levodopa is the most effective treatment for symptoms. It is a precursor to dopamine and converted to dopamine once transported into the brain.
Common names include:
  • Dopar
  • Larodopa
Levodopa and Carbidopa
Common names include:
  • Carbidopa/levodopa (Sinemet)
  • Carbidopa/levodopa controlled-release (Sinemet CR)
  • Carbidopa/levodopa/entacapone (Stalevo)
Levodopa helps increase the amount of dopamine within the brain. This can help improve symptoms of Parkinson’s disease, particularly rigidity and slowness. Unfortunately, the body metabolizes (breaks down) this drug very quickly, so you’ll have to take another dose fairly often. As a result, you’ll often be given a medicine that combines levodopa with carbidopa, a substance that slows the breakdown of levodopa. You’ll only have to take this medicine every 4-6 hours.
If you’re taking levodopa alone, don’t take vitamin B6 supplements without your doctor’s knowledge since they can speed up the breakdown of levodopa. Because bananas, egg yolks, lima beans, meats, peanuts, and whole grain cereals all contain large amounts of vitamin B6, ask your doctor how much of these food items you should eat on a daily basis.
Some people notice less effect from levodopa and levodopa/carbidopa combinations over time. The drugs may seem less effective, or their benefits may stop even before it’s time for the next dose. If this happens, talk to your doctor about increasing the dosage or increasing how frequently you take the medicine.
Don’t ever suddenly discontinue using these medicines, unless your doctor advises it.
Possible side effects include:
  • Nausea
  • Vomiting
  • Dizziness
  • Dry mouth
  • Nightmares
  • Nervousness
  • Anxiety
  • Decreased appetite
  • Increased intestinal gas
  • Low blood pressure
  • Palpitations
  • Confusion
  • Agitation
  • Psychosis, paranoia, mania
  • Hallucinations, delusions
  • Nightmares, vivid dreams, night terrors
Stalevo adds entacapone, a COMT inhibitor (see below), to the levodopa/carbidopa combination. Side effects are reported to be those described above, plus those listed below for entacapone (Comtan).
Dopamine Agonists
Common names include:
  • Bromocriptine (Parlodel)
  • Cabergoline (Dostinex)
  • Pramipexole (Mirapex)
  • Ropinirole (Requip)
  • Apomorphine (Apokyn)
  • Rotigotine (Neupro) patch
These drugs affect the brain in a way similar to dopamine. They may be given by themselves early in Parkinson’s disease, or along with other medicines (like levodopa) later in the course of the disease. Dopamine agonists cause less motor fluctuations and dyskinesias due to the longer duration of action.
Some people develop hallucinations or confusion while taking dopamine agonists and have to stop taking the medicine. Do not use alcohol while you are taking a dopamine agonist. You will have unpleasant and potentially dangerous symptoms, including nausea, vomiting, fast heart rate, blurry vision, chest pain, headache, and extreme weakness.
Possible side effects include:
  • Dizziness
  • Drowsiness
  • Dry mouth
  • Nausea, vomiting
  • constipation
  • Headache
  • Ankle edema
  • Sudden low blood pressure when you first stand up (which can result in falling)
  • Sudden sleep attacks (These attacks can be very dangerous if they occur while you’re driving.)
  • Hallucinations, delusions
  • Compulsive gambling
Other Side Effects
Apomorphine (Apokyn) is a short acting dopamine agonist given as an injection in advanced cases. The medicine was approved by the FDA for wearing-off spells. These spells occur in patients who have been receiving long-term dopamine replacement therapy. The side effects are similar to that of the dopamine agonists. But, nausea and vomiting have been reported to occur more often.
Cabergoline (Dostinex) has also been associated with the risk of serious heart damage. The dopamine agonist bromocriptine (Parlodel) has rare, but significant, side effects (such as pericardial, pleural, and pulmonary fibrosis). Talk to your doctor if you have been taking these medicines and are concerned about potential side effects.
Monoamine Oxidase Type B Inhibitor
Common brand names include:
  • Selegiline (Eldepryl)
  • Rasagiline (Azilect)
Selegiline and rasagiline are usually given along with levodopa or levodopa/carbidopa combinations. Both interfere with the breakdown of dopamine in the brain.
You may have a severe reaction if you take this medicine along with the narcotic painkiller, meperidine (Demerol).
If you are taking selegiline at higher-than-usual doses, you may have a sudden, dangerous spike in blood pressure if you eat or drink things that contain a substance called tyramine. Tyramine is found in:
  • Aged cheeses
  • Beer, wine, and other alcoholic beverages
  • Smoked or pickled meats, chicken, fish, and cheeses
  • Caffeinated foods and beverages (colas, coffee, tea, chocolate)
  • Nonprescription medicines for colds, allergies, sinuses, cough, asthma, hay fever, and appetite control
Call your doctor right away if you notice:
  • Severe headache
  • Stiff neck
  • Chest pain
  • Abnormally fast or slow heartbeat
  • Severe nausea and vomiting
  • Increased sweating
Possible side effects include:
  • Dry mouth
  • Dizziness
  • Sudden low blood pressure when you first stand up (which can lead to falls)
  • Difficulty sleeping
  • Nausea, vomiting (mild)
  • Visual hallucinations
  • Agitation
There are several medicines that should not be taken while taking selegeline and rasasgiline. Some of these include:
  • selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), and tricyclic antidepressants
  • Antibiotic lienzolid (Zyvox)
  • Certain decongestants and stimulants (amphetamines, ephedrine, phylephrine, pseudoephedrine)
  • Cyclobenzaprine (Flexeril)
  • Dextromethorphan
  • Certain opioid analgesics: methadone, tramadol
  • Other monoamine oxidase (MAO) inhibitors
COMT Inhibitors
Common names include:
  • Tolcapone (Tasmar)
  • Entacapone (Comtan)
COMT inhibitors are taken with levodopa preparations. They help decrease the rate of breakdown of levodopa, so more is available to work in the brain.
These medicines can cause severe liver problems, so your doctor will probably run regular tests to monitor your liver function.
Possible side effects include:
  • Brownish-orange urine
  • Moderate-to-severe diarrhea
  • Dizziness, lightheadedness
  • Hallucinations and confusion (especially in the elderly)
  • Headaches
  • Somnolence
Anticholinergics
Common names include:
  • Trihexyphenidyl (Artane)
  • Benztropine (Cogentin)
These medicines can decrease tremor and stiffness and improve muscle control.
You’ll have less chance of stomach irritation if you take these medicines with food. Don’t take an anticholinergic medicine within the hour after you’ve taken medicine for diarrhea; the diarrhea medicine will interfere with the actions of the anticholinergic medicine. Don’t use alcohol while you're taking anticholinergic medicines. Check with your doctor before using any medicines that make you drowsy.
Before you begin treatment with anticholinergic medicines, get your eyes checked by an ophthalmologist.
Possible side effects include:
  • Drowsiness
  • Dizziness
  • Sensitivity to bright lights
  • Dry mouth
  • Urinary retention
  • Blurred vision
  • Constipation
  • Fast heartbeat, palpitations
  • Mood changes
  • Memory difficulties
  • Confusion
  • Hallucinations
Amantadine
Common brand name:
  • Amantadine (Symmetrel)
Amantadine can help reduce stiffness and tremor and improve muscle control. Sometimes this medicine stops working after you’ve been taking it for a while. Your doctor may recommend that you take a break (a “drug holiday”) from the medicine and then restart it. This may help the drug regain its effectiveness.
Don’t drink alcohol while you’re using amantadine. If you begin to feel depressed or suicidal, talk with your doctor right away.
Possible side effects include:
  • Dizziness, especially when first rising (which may increase risk of falls)
  • Confusion
  • Blurry vision
  • Difficulty concentrating
  • Dry mouth
  • Purplish-red blotchy skin rash
  • Depression
  • Nightmares
  • Insomnia
  • Hallucinations
  • Urinary retention
  • Lower extremity edema
Researchers are focusing on neuroprotective medicines. These medicines may be able treat the underlying problems causing Parkinson’s, not just the symptoms.

Special Considerations

If you are taking medicines, follow these general guidelines:
  • Take your medicine as directed. Do not change the amount or the schedule.
  • Do not stop taking them without talking to your doctor.
  • Do not share them.
  • Know what the results and side effects. Report them to your doctor.
  • Some drugs can be dangerous when mixed. Talk to a doctor or pharmacist if you are taking more than one drug. This includes over-the-counter medicine and herb or dietary supplements.
  • Plan ahead for refills so you don’t run out.

When to Contact Your Doctor

  • The drug does not seem to be working.
  • You have undesired side effects.
  • You begin to have stomach problems while taking the medicine.

References

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Conn HF, Rakel RE. Conn’s Current Therapy 2002. 54th ed. Philadelphia, PA: WB Saunders Company; 2002.
Jankovic J, Shannon KM. Movement Disorders. In: Bradley WG, Daroff RB, et al. eds. Neurology in Clinical Practice. 5th ed. Philadelphia, Pa: Butterworth Heinemann Elsevier; 2008. ExpertConsult Web site. Available at http://www.expertconsultbooks.com . Accessed Dec 13, 2009.
Parkinson Disease. National Institute of Neurological Disorders and Stroke website. Available at: http://www.ninds.nih.gov/disorders/parkinsons%5Fdisease/parkinsons%5Fdisease.htm. Accessed August 22, 2012.
Nauert R. Medication induced gambling compulsion. PsychCentral website. Available at: http://psychcentral.com/news/2007/02/09/medication-induced-gambling-compulsion/611.html. Accessed April 2, 2009.
Parkinson's disease. EBSCO DynaMed website. Available at: http://www.ebscohost.com/dynamed/what.php. Updated June 6, 2012. Accessed August 22, 2012.
Managing your PD. Parkinson’s Disease Foundation website. Available at: http://www.pdf.org/en/managing%5Fpd. Accessed August 22, 2012.
Rowland LP, Merritt HH. Merritt's Neurology. Philadelphia, PA: Lippincott Williams & Wilkins; 2000.
WR Wayne Martin. Dopamine agonists and the risks of valvular heart disease. Nature Clinical Practice Neurology. 2007;3:426-427.
4/10/2007 DynaMed's Systematic Literature Surveillance http://www.ebscohost.com/dynamed/what.php: United States Food and Drug Administration. FDA announces voluntary withdrawal of Pergolide products [press release]. March 29, 2007. US Food and Drug Administration website. Available at: http://www.fda.gov/bbs/topics/NEWS/2007/NEW01596.html .
11/30/2010 DynaMed's Systematic Literature Surveillance http://www.ebscohost.com/dynamed/what.php: US Food and Drug Administration. Propoxyphene: withdrawal—risk of cardiac toxicity. US Food and Drug Administration website. Available at: http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm234389.htm. Published November 19, 2010. Accessed November 30, 2010.
3/11/2013 DynaMed's Systematic Literature Surveillance http://www.ebscohost.com/dynamed/what.php: UCB. Neupro approved by US FDA for Parkinson's disease and restless legs syndrome. Available at: http://www.ucb.presscentre.com/News/Neupro-approved-by-U-S-FDA-for-Parkinson-s-Disease-and-Restless-Legs-Syndrome-2d6.aspx. Published April 3, 2012. Accessed March 11, 2013.

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