On Wed, 30 Oct 1996 14:11:35 -0500
Ralph Reichert wrote:

>Subject:       Artane or Cogentin for Tremor?
>Has anyone found these drugs helpful for PD tremor?  Any serious adverse
>effects? Compatable with Eldepryl?

and on 31 Oct Barbara Jensen asked:

>Would really appreciate any input from fellow PWP's with tremor.
>I will try Amantadine(Symmetrel) next and then Permax.Would really
>appreciate any input from fellow PWP's with tremor.
>I will try Amantadine(Symmetrel) next and then Permax.

The following is an excerpt from:
AN EXAMINATION OF MEDICATIONS BOTH COMMONLY AND OCCASIONALLY USED IN
TREATING PARKINSON'S DISEASE, by Neal Slatkin, MD.

NOTE: This paper, and much more information can be found in our PD archives
and on the web (for those with browsing capability):
http://neuro-chief-e.mgh.harvard.edu/parkinsonsweb/Main/PDmain.html
The Parkinson's Web.
---------
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.

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.

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.

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.)

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.