>The following is most of the newsletter "Moving Forward" from City of Hope
>Parkinson's Center in Duarte, CA.  This newsletter is all about medications
>using in the treatment of PD.  I will be breaking the file into at least two
>parts so as not to over do the system.  I think it will give us all a point
>of reference for the various medications.  I have formatted this file such
>that titles are in capitals and each paragraph has a blank line preceeding
>it.  Lines starting with "+ " are bulleted lines.
>
>Note:  If you are on AOL and are using MS WORD 6.0 on a PC type computer, I
>will send the formatted DOC file to those requesting it.  This is the full
>newsletter in one file.  The file is 14 pages in length.
>
>
>Start part I
>====================================================
>
>AN EXAMINATION OF MEDICATIONS BOTH COMMONLY AND OCCASIONALLY USED IN TREATING
>PARKINSON'S DISEASE
>
>Neal Slatkin, MD
>
>NOTE: This paper is a reprint of most of the City of Hope Parkinson's Center
>Newsletter, Moving Forward, Summer 1995. This reprint is with the authors
>approval.  The author would like to acknowledge and thank those who reviewed
>the paper for content.  The reviewers were John S. Kovach, MD; Matt Kurth,
>MD, PhD; Jeff Chapman, PharmD; and Beatrice Decone, PharmD; with editing by
>Stephanie Unger and production by Robin Moore.
>
>INTRODUCTION
>
>In this special issue of Moving Forward we are providing an extended
>examination of the various medications that have been used by persons with
>Parkinson's disease. The purpose is to provide patients and caregivers with
>information on these medications as a clarification of the many approved and
>non-approved medications which have entered the array of medical treatments
>for Parkinson's disease and associated symptoms. The information contained in
>this newsletter is not intended as either medical advice to patients on the
>use of their medications or as a replacement for information received from
>the patient's physician. Patients having questions about their medications
>should discuss them with their physicians. Like all medications, those used
>in Parkinson's treatment require the regular guidance and monitoring of the
>prescribing physician.
>
>Two categories of medications are included in this discussion, as follows:
>+ Those drugs intended to treat the primary motor symptoms of Parkinson's
>disease, such as rigidity, rest tremor and bradykinesia and
>+ Those that are used in treating symptoms frequently associated with
>Parkinson's, such as depression, problems with sleep, action tremor,
>light-headedness, etc.
>
>For each class of medication three basic pieces of information are provided:
>+ A description of its established or possible value in Parkinson's treatment
>and its basic mechanisms of action (if known).
>+ Some of the possible side effects which might occur when these medications
>are taken
>+ A description of situations in which the medications should be used with
>caution or avoided altogether, situations that are called contraindications
>by physicians and pharmacists.
>
>Since this information is intended to serve as a quick-reference resource,
>rather than as a comprehensive guide to each medication, only the most common
>or serious side effects and contraindications of each medication are
>provided. Moreover, although each medication approved for treatment within
>the United States undergoes extensive evaluation, new side effects are often
>recognized only after a medication has been in use for many years. Any list
>of potential medication-associated problems can therefore become quickly
>dated as new side effects and warnings are reported.
>
>This review is intended only as a means of enhancing your basic understanding
>of medication effects and facilitating communication with your physician.
>
>GENERAL APPROACH TO MEDICATIONS AND PRECAUTIONS
>
>Before leaving your doctor's office be sure that you thoroughly understand
>the following:
>+ why a medication has been prescribed
>+ how and when to take it
>+ its possible side effects and contraindications.
>
>Always bring a list of all of your current medications with you to your
>appointments. It is also wise to keep an updated list in your purse or
>wallet.
>
>Some patients use several different pharmacies in an attempt to minimize the
>cost of their medications. In general, it is best to avoid using more than
>two pharmacies, including mail-order pharmacies. Some pharmacists can be very
>helpful in advising you about your medications by providing information on
>medication side effects and potential drug interactions. However, a
>pharmacist can only give you good advice if he or she knows the names of all
>of the medications you are taking.
>
>APPROVED MEDICATIONS
>
>Before a medication can be sold or distributed within the United States, it
>must be approved by the Food and Drug Administration (FDA) as safe and
>effective. Not all substances, however, which are promoted or used for
>medical purposes are classified as medications, or are subject to FDA
>regulations. For example, most substances sold in health food stores have
>neither been proven safe nor effective for their various promoted uses.
>Further complicating matters, it is common practice in medicine for even
>approved medications to be utilized for "unapproved" purposes, that is in
>conditions for which they have not been specifically proven safe or
>effective.
>
>With the exception of Motilium (domperidone) all of the medications discussed
>in this newsletter are FDA approved. You should understand, however, that
>some of these medications have not been specifically approved for the exact
>purposes discussed. A number of other substances which are not medications
>are also discussed. You are again reminded that these have generally not been
>rigorously tested or shown as safe or effective in the treatment of any
>condition.
>
>PREGNANCY AND BREAST FEEDING
>
>Most medications are contraindicated when a woman is pregnant or breast
>feeding. Women who are actively pursuing conception, or who are pregnant or
>breast feeding must consult with their physician before taking any
>medication.
>
>PREVENTING DRUG INTERACTIONS
>
>Whenever you have a new medication prescribed, make sure your physician knows
>the names of all other medications you are taking (including eye drops,
>non-prescription medications, special "health" and nutritional preparations,
>birth control pills, hormones, etc.). Combinations of medications can cause
>problems different from or more severe than side effects of individual
>medications. Alcohol use is contraindicated with a number of medications.
>Before taking alcohol and any medication, check with your doctor or
>pharmacist.
>
>SLEEPINESS
>
>Many medications can cause sleepiness, especially for the first several
>doses. Don't plan to operate potentially dangerous machinery or do much
>driving within the first several days of taking a new medication.
>
>STOPPING MEDICATIONS
>
>It is usually unwise to suddenly discontinue a medication that you have been
>taking for more than a month or two. Suddenly stopping stimulant medications,
>anti-seizure drugs, certain pain relievers, antidepressants, tranquilizers
>and various heart medications can lead to potentially severe withdrawal
>symptoms. Consult with your physician whenever possible before you stop
>taking a medication. If a new medication causes severe side effects, it may
>be acceptable to delay the next scheduled dose until you have had an
>opportunity to speak with your doctor. Finally, remember that each person is
>unique and that your reaction to a medication may be quite different from
>that of a friend or relative. If you expect side effects to occur, you are
>bound to experience them. Even placebos--inactive sugar pills--can have a
>high incidence of side effects, when patients expect or are fearful of bad
>reactions.
>
>IMPORTANT INFORMATION
>AND DISCLAIMER
>
>The information in this newsletter is provided solely for the purpose of the
>general information of the reader. It is not in any respect intended as
>medical advice for patients, nor does it imply treatment recommendations of
>City of Hope National Medical Center or the National Parkinson's Foundation.
>Some of the medications listed are not approved by the United States Food and
>Drug Administration (FDA) for the treatment of Parkinson's disease; and/or
>may not be approved for the purposes discussed; and/or may not be approved
>for use within the United States. You are strongly encouraged to consult your
>doctor should you have questions regarding these or other medications.
>
>
>MEDICATIONS USED TO TREAT PRIMARY MOTOR SYMPTOMS
>
>DOPAMINE REPLACEMENT MEDICATIONS
>
>SINEMET (CARBIDOPA/LEVODOPA)
>USUAL TABLET SIZES: 10/100 (OFTEN BLUE), 25/100 (OFTEN YELLOW), 25/250 (OFTEN
>BLUE)
>
>This is the most commonly used medication in the treatment of Parkinson's
>disease and, generally, the most effective. Levodopa is the active medication
>and must be converted by the brain into dopamine in order to have a
>beneficial effect. Carbidopa has no direct anti-Parkinson's effect, but
>instead facilitates entry of levodopa into the brain by preventing its
>metabolism into dopamine outside of the brain. In doing so, carbidopa also
>helps prevent some levodopa-related side effects such as nausea, vomiting and
>palpitations.
>
>Sinemet is the brand name of the original carbidopa-levodopa combination
>tablet. Many generic carbidopa-levodopa combinations are now available. For
>some patients, generic medications work as well as brand name Sinemet; for
>other patients, particularly those with troublesome on-off fluctuations or
>dyskinesias, treatment with brand name Sinemet may be preferred.
>
>When taking Sinemet for the first time, take it along with food to decrease
>the chance of nausea and vomiting. After Sinemet has been used for more than
>four to six months, most patients can begin to take it 30 to 45 minutes
>before meals. Taking Sinemet before meals ensures better and more predictable
>drug absorption.
>
>SIDE EFFECTS OF SINEMET (LEVODOPA)
>
>+ Nausea and vomiting, as well as vague symptoms of gastrointestinal
>discomfort, which usually subside after weeks or months of treatment
>+ Constipation that can cause discomfort and may require a change in diet or
>a special bowel program
>+ A drop in blood pressure, the primary symptoms being those of
>light-headedness, dizziness, neck pain and/or increased imbalance
>+ Increased sleepiness, particularly following the morning and afternoon dose
>of medication
>+ Increased nightmares, hallucinations and confusion during the later part of
>the day or at night
>
>POTENTIAL DELAYED SIDE EFFECTS OF SINEMET (LEVODOPA)
>
>After five years of levodopa treatment, approximately 50 percent of patients
>develop delayed side effects. These can vary greatly in severity from patient
>to patient and some patients fail to develop significant long-term effects
>even after 10 to 15 years of therapy. Potential delayed side effects include:
>
>+ Abnormal and involuntary movements: Twisting and dancing movements of the
>arms, legs and trunk (dyskinesias) and unusual muscle contractures or cramps,
>especially in the foot (dystonia)
>+ Wearing off: A tendency for the benefits of each individual dose of
>medication to wear off in a predictable manner before the next is scheduled
>to be taken
>+ On-off episodes: Unpredictable fluctuations in motor function, not clearly
>associated with the taking of medications
>+ The potential for long-term complications of carbidopa/levodopa has led to
>controversy about when in the course of Parkinson's to start levodopa
>treatment. It is appropriate to discuss concerns about such matters with your
>doctor.
>
>CONTRAINDICATIONS
>
>+ Certain forms of glaucoma
>Patients should have eye pressures checked at the beginning of treatment and
>at frequent intervals after starting treatment.
>+ Malignant melanoma
>Controversial, but if a patient has a history of melanoma, this should be
>brought to the attention of his or her physician.
>+ Peptic ulcer disease
>Having this disease may also be a relative contraindication.
>+ Stopping levodopa
>In general, levodopa should be slowly tapered off over the course of several
>days. Abruptly stopping Levodopa can lead to a severe syndrome of increased
>muscular rigidity, elevated body temperature and increased confusion
>(malignant hyperthermia). If these problems develop, they require immediate
>medical attention.
>
>SINEMET CR (CONTINUOUS RELEASE CARBIDOPA/LEVODOPA)
>25/100 PINK TABLET, 50/200 TAN TABLET
>
>Sinemet CR is a long-acting carbidopa /levodopa preparation that releases
>levodopa more slowly into the intestines. This results in more sustained
>levodopa absorption, with a longer duration of action and, in general, lower
>peak-dose effects. Due to lower peak-dose levels, some patients may not
>"turn-on" with Sinemet CR and may need to take regular Sinemet with it,
>especially at the time of the first morning dose. Sinemet CR may be broken in
>half, in which case its effects are intermediate between regular Sinemet and
>unbroken Sinemet CR. Crushing this medication is not advised, as it
>eliminates its slow-release properties.
>
>The four situations in which Sinemet CR is generally used are as follows:
>+ Early in the course of treatment, as the initial form of levodopa therapy
>+ When "wearing off" problems begin to appear (Sinemet CR can help by
>prolonging the duration of levodopa action)
>+ When there are predictable peak dose dyskinesias (Sinemet CR can help by
>decreasing peak levodopa levels)
>+ When there are parkinsonian mobility problems at night. (Sinemet CR can
>help by producing a more sustained level of levodopa through the night and
>improve sleep. This may also help to decrease early morning dystonia.)
>
>SIDE EFFECTS OF SINEMET CR (CONTINUOUS RELEASE LEVODOPA)
>
>The side effects for Sinemet CR are the same as for regular release Sinemet
>discussed earlier. Some older patients may show increased confusion with
>Sinemet CR, whereas others will have fewer problems on this preparation.
>Those patients who do not "turn on" with Sinemet CR, may need to couple this
>medication with a small dose of regular Sinemet. Sinemet CR may precipitate
>the appearance of dyskinesias in some patients, or cause an aggravation of
>pre-existing dyskinesias.
>
>DOPAMINE AGONISTS
>
>PERMAX (PERGOLIDE), PARLODEL (BROMOCRIPTINE), APOMORPHINE
>
>INVESTIGATIONAL AGENTS: CABERGOLINE, ROPINEROLE, PRAMIPEXOLE
>
>Dopamine agonists are commonly used as adjuncts to Sinemet in treating the
>motor symptoms of Parkinson's disease. Drugs in this class stimulate the
>brain directly by mimicking dopamine and do not have to be converted into
>other compounds. Although generally not as effective as Sinemet in decreasing
>symptoms, these agents may offer the Parkinson's patient other treatment
>advantages including: (a) a longer duration of action, (b) absorption which
>is generally not limited by the presence of food or protein; and, (c)
>effectiveness even when levodopa ceases to be effective (controversial).
>
>SIDE EFFECTS OF DOPAMINE AGONISTS
>
>+ Low blood pressure upon standing, causing symptoms of light-headedness,
>dizziness, neck pain and imbalance
>+ Hallucinations, confusion, or bad dreams
>+ Nausea, stomach upset, constipation and occasional vomiting
>+ Ankle swelling, or edema
>+ New or worse dyskinesias, though these generally subside with lowering of
>the levodopa dose
>+ Note: A rare side effect of treatment with some of these drugs is increased
>shortness of breath, caused by scarring around the heart or within the lung.
>This complication requires that the patient be promptly tapered off this
>medication.
>
>APOMORPHINE
>
>This dopamine agonist medication is no longer being manufactured in the
>United States and has not been approved by the Food and Drug Administration
>(FDA) as an anti-parkinsonian medication. It is being utilized in many other
>countries throughout the world as a dopamine agonist (see description above).
>Unlike other dopamine agonists available in the United States (pergolide,
>bromocriptine), Apomorphine can be injected. When administered in this
>manner, it has a rapid onset of action. It can be very useful for reversing
>off periods and may also be useful for the treatment of various parkinsonian
>dystonias. The major side effects of treatment are severe problems with
>nausea and vomiting and a fall in blood pressure upon standing. To a great
>extent, these side effects can be prevented by taking domperidone. Skin
>nodules can form, at frequent injection sites if apomorphine is injected
>subcutaneously.
>
>SYMMETREL (AMANTADINE)
>100 MG CAPSULES (RED, YELLOW), SUSPENSION (50 MG / 5 CC = TEASPOON)
>
>Symmetrel (amantadine) is most frequently used as an adjunctive agent in the
>treatment of motor symptoms. It was initially introduced to prevent infection
>with influenza A virus. After its introduction, however, it was
>serendipitously found to have anti-Parkinson's effects. The mechanism of
>anti-parkinsonian action of this medication is still unclear, though it may
>increase dopamine release or block certain excitatory brain receptors (the
>NMDA receptors) and thereby improve movement.
>
>SIDE EFFECTS OF SYMMETREL (AMANTADINE)
>
>+ Nausea, light-headedness, difficulty with sleep, ankle swelling or edema,
>hallucinations
>+ Anxiety, bad dreams, dry mouth, difficulty with urination and increased
>problems of constipation
>+ Occasional mottling of the skin (livedo reticularis), which may require
>discontinuation of this medication
>+ Symmetrel should be slowly discontinued or malignant hyperthermia could
>result. (See earlier discussion on stopping carbidopa/levodopa.)
>
>ELDEPRYL (SELEGILINE)
>5 MG WHITE TABLETS, MAXIMUM DOSE _ 10 MG/DAY
>
>Eldepryl (selegiline) is a monoamine oxidase type B inhibitor (MAO-B
>Inhibitor). Monoamine oxidase is an enzyme used by the brain to metabolize,
>or break down, dopamine. Eldepryl often prolongs the effects of levodopa
>therapy by prolonging dopamine action in the brain. The metabolism of
>dopamine can also cause potentially harmful substances (called free radicals)
>to accumulate in the brain. By inhibiting dopamine metabolism, Eldepryl may
>inhibit the production of these substances and thereby have a protective
>action.
>Eldepryl has been reported to be of value in three situations, as follows:
>+ In the early symptomatic treatment of Parkinson's before levodopa is begun
>+ For "wearing off" problems, by prolonging levodopa action
>+ As a "neuro-protective" agent or "free-radical scavenger" to slow
>Parkinson's disease progression (controversial)
>
>SIDE EFFECTS OF ELDEPRYL
>
>+ Nausea, stomach upset, light-headedness
>+ Insomnia, especially if taken after 1 or 2 pm
>+ Confusion, hallucinations and nightmares (more commonly encountered in
>older patients, or those who have had Parkinson's for many years)
>+ Occasionally Eldepryl may worsen dyskinesias or cause other side effects
>similar to those of levodopa excess
>
>CONTRAINDICATIONS
>
>When combined with anti-depressant medications, Eldepryl can uncommonly cause
>a severe syndrome characterized by increased rigidity, jerking movements of
>the arms and legs, agitation, confusion, restlessness, fever, shivering and
>sweating ("serotonin syndrome"). The simultaneous use of anti-depressant
>medications and Demerol-a pain reliever _ should be avoided in patients
>taking Eldepryl. Patients taking Eldepryl may be advised to wear a
>Medic-Alert -type bracelet to decrease the likelihood of receiving a
>medication that may interact with Eldepryl.
>
>
>ANTI-CHOLINERGIC MEDICATIONS
>
>
>ARTANE (TRIHEXYPHENIDYL), COGENTIN (BENZTROPINE MESYLATE) AND OTHERS
>
>Anti-cholinergic medications are historically the first type of medications
>to be successfully used in the treatment of Parkinson's disease and may still
>be of adjunctive value in reducing tremor and rigidity. Many medications with
>strong anti-histamine properties such as Benadryl (diphenhydramine) and
>Periactin (cyproheptadine) also have anti-cholinergic effects and may also be
>useful.
>
>SIDE EFFECTS OF ANTI-CHOLINERGIC MEDICATIONS
>
>+ Dry mouth, blurring of near vision, constipation, urinary hesitancy and
>retention (especially in men)
>+ Mental confusion, decreased memory and hallucinations (especially in older
>patients or those who are already having problems with mental clarity)
>+ Patients with hiatal hernia and gastroesophageal reflux may experience
>increased symptoms of "heart burn"
>
>CONTRAINDICATIONS
>
>Patients who have certain types of glaucoma, who have severe problems with
>urination, or who have unusually severe problems with confusion or
>forgetfulness, should not take anti-cholinergic medications.
>
>====================================================
>
>End Part I
 
>Regards,
>Alan
>Please send the complete file for MSWord 6.0 to my e-mail address via
internet to:
        ATI_Aiken @Augusta.net
 
Thanks,
 
Bernie Bessette