Dear Bonnie,
Thanks very much for your detailed 12 Aug 1998 response to my questions
regarding guidelines.
I did not initially bring these questions to Aliza's neurologist for the
following reasons:
I expected to get a more rapid and informative response by posing the questions
on this list than if I called or wrote to Aliza's Neurologist.Within
hours,Ron Vetter
sent us guidelines from Roche,Bob Cowan sent very useful info,then your
excellent response,
and Brian Collins' enlightening insights.Now we have information to ask him
intelligent
questions.There is an additional problem here for us,since Tasmar has not
yet been
approved for use here in Israel.Thus our primary care physician doesn't want
any part of
it.Thus any recommended tests to check for contra-indications such as liver
tests have to be
handled through Aliza's neurologist who prescribed the Tasmar whereas
normally tests are
ordered through her readily-accessible primary care physician.

Re my first question about taking Tasmar simultaneously with Sinemet
CR,Aliza's neurologist
did not give us guidelines at all when he first prescribed taking two pills
to start and then
going to three.Since she was taking Sinemet CR at 5 hour intervals,it seemed
logical to
synchronize the Tasmar with the Sinemet and therefore take them together.At
the second meeting,
after taking the Tasmar for about four weeks,and noting that there was
really no noticeable
improvement except for apparently sleeping better,he suggested taking six
pills per day.When I
asked about taking it with the Sinemet CR 5 times a day ,he agreed without
comment.After two
days of doing this Aliza began to feel shaky after about three hours.We
thought two things:
1.The Tasmar is not making the levadopa last six hours.
2.Perhaps,there was an overdosage.
We did not associate Aliza feeling shaky with diskinesia which up till now
she has not felt.
Since yesterday morning,she is taking Tasmar with her 7:00AM Sinemet CR and
then at 1:00PM
and 7:00PM and felt better  in the afternoon which supports the overdose
hypothesis.
However,last night,she slept very poorly.

Re my second question on how one knows to reduce Sinemet CR and/or Sinemet
when taking Tasmar,
Aliza does not have ON/OFF times per se.Her major symptoms are
Bradykinesia(slowness) and poor
balance all the time.Her Neurologist did not suggest any reductions.Based on
the Roche guidelines,
she should not, since she is well below 600mg of effective levadopa per day.

Re my third question on when one knows the Tasmar dosage is too much or too
little,it would be
helpful to have a detailed list of what side-effects to look for.

Re my fourth question of the best times to take three Tasmar pills,the Roche
guidelines
clearly state a six hour interval with the first pill of the day with the
Sinemet.
What do you mean by "GENERAL" information?What can we expect the doctor to
say?He scarcely knows
Aliza and does not have any magic information up his sleeve.

Re my fifth question re when to take six pills,the Roche guideline is to
take two pills
together at six hour intervals.This means in Aliza's case that she does not
have the benefit
of the Tasmar from 1AM to 7AM assuming its benefit lasts six hours.It is not
clear why this
should be better than spreading the six pills over four hour intervals
around the clock.

Re my sixth question,as to how long a Tasmar pill lasts,the conclusion that
it remains in the
system 4-6 hours based on a half-life of 2-3 hours assumes a linear decay in
the system.
It is interesting that if the decay was exponential,then if the half-life is
3 hours,then after
six hours there would still be a quarter left rather than nothing left as
predicted by the linear
assumption.After 12 hours,there would still be one sixteenth left.So the
linear decay is very
significant in avoiding cumulative effects due to successive pills.

Re my seventh question,as to what PD symptoms are most commonly helped,it
would be interesting to
know which specific symptoms are helped by enhancing Sinemet and which are
not.Aliza's Neurologist
told us that her slowness and loss of balance are not promising symptoms to
be helped.So maybe her
use of Tasmar is a wasted expensive effort.

Re my eighth question,as to common over-dosage effects,it would be helpful
to have a more
comprehensive list of over-dosage effects than those you mentioned.What lead
us to think
Aliza was over-dosed with five Tasmar pills was her feeling shaky/jumpy.Is
this a reasonable
effect?Such a feeling could be due to  a variety of drug interactions,for
example.In Aliza's case,
she is taking 11 different drugs.

Bonnie,your responses to my questions are very helpful.
We will try to develop an "open-line" with Aliza's new neurologist as you
suggested.
I was already rebuffed once by him for taking up too much of his time.
I sent him faxes which his office didn't give him.
But he did promise to provide answers to written questions.
Because of the problem of accessibility,we are considering switching to
another PD specialist
who has a nurse and social worker available for patient support.

Thanks again.
Gil Lieberman,CG for Aliza