WE MOVE - Parkinson's Disease - Web Chat Transcript 9/30/1999
<http://www.wemove.org:/par_pdwc9_30_99.html>

AH Moderator: I've lately been experiencing depression and I'm currently on
PD medication. My doctor wants to put me on an antidepressant. Which ones
are safe to take?

Dr. M Stacy: Depression is reported in approximately 50% of PD patients,
and often responds to antidepressant therapy. There are 2 classifications
of antidepressant agents. One is the tricyclic antidepressants such as
Elavil, Pamelor or Trazadone. While these drugs do not interfere with other
PD medications, they may cause dry mouth, memory difficulty or urinary
hesitancy. Another classification - the SSRIs - such Paxil, Effexor Zoloft,
and Prozac, are also quite useful in treating the symptoms of depression,
and may be better tolerated. In severe depression ECT (electroconvulsive
therapy) may be considered, especially if patients are not responding to
medications or are suicidal.

AH Moderator: I'm taking hormonal replacement therapy. Will this affect my
PD medication?

Dr. K Sethi: There is no evidence to suggest that HRT in any way decreases
the efficacy of Parkinson medications. In fact, there is a suggestion that
estrogen may help patients with Parkinson's disease. I have personally seen
patients with Parkinson's disease worsen when they use anti-estrogen drugs
for treatment of cancer. Therefore, you can continue with your HRT.

AH Moderator: Can a man with PD take Viagra?

Dr. M Stacy: The short answer is "yes." We reviewed 21Parkinson's patients
in our clinic taking Viagra, ranging from 25 to 100 milligrams. The drug
was effective in 19 of the 21 patients, and 16 men continue to use the
drug. In this series none of the men reported adverse side effects. But
since that time 2 of our patients have reported dizziness with the drug,
and one man reported a change in his color vision. All of these side
effects lasted less than 30 minutes.

AH Moderator: Do PD or PD medications affect bladder function?

Dr. K Sethi: Bladder dysfunction is very common in elderly men who also
have prostate enlargement in addition to their Parkinson's disease.
Parkinson's disease may also affect bladder function by causing it to be
over active, resulting in incontinence. Most of the drugs used to treat
Parkinson's do not worsen the problem, but anticholinergics and sometimes
Symmetrel may worsen the bladder problem. It is very important for a
urologist to be involved in the care of PD patients who are experiencing
urinary problems. I do not believe that Sinemet causes incontinence.

Dr. M Stacy: There are several newer medications that can help urinary
incontinence. One is a pill, Detrol. At doses ranging from one to four 2 mg
tabs daily, bladder symptoms can be improved. If nighttime incontinence is
the major problem, reducing fluid intake from 6 PM on may be helpful. You
may also take Detrol only at bedtime. Another trick to reduce nighttime
urinary frequency is to use a DDAVP inhaler. This will reduce bladder
filling for approximately 6 hours in some patients. But I would caution
that it is not always effective and is fairly expensive.

AH Moderator: Why would you recommend Sinemet CR as opposed to regular
Sinemet?

Dr. M Stacy: Sinemet CR is a "controlled release" form of
carbidopa/levodopa. Its advantage in some patients is that it is more
slowly absorbed from the stomach than immediate release Sinemet, and
therefore can be taken less frequently. In patients with early PD, Sinemet
CR may be used easily at 5 hour dosing intervals, while immediate release
Sinemet is given more frequently Ð usually at 4 hour intervals. With motor
fluctuations, a combination of the two may be necessary. As an attempt to
help define when to use these drugs, it is important to note whether a
patient has dyskinesias 2 hours after taking Sinemet or at the end of the
dosing interval (4 hours). Peak-dose dyskinesia at 2 hours may respond to
Sinemet CR, while the trough-dose (or wearing-off) dyskinesia at 4 hours is
usually more easily treated with regular Sinemet . However, the use of
these two formulations is highly variable, and requires good patient and
physician communication.

AH Moderator: Can you tell me about eye problems and blurry vision? What
can we do to help us read again?

Dr. K Sethi: Problems with vision occurring in patients who are elderly,
with or without Parkinson's, are due to a variety of causes, including
cataracts, trouble with near vision, as happens in normal elderly and other
diseases of the eye. Patients with Parkinson's disease on anticholinergic
drugs can develop blurring of vision. There is no direct deleterious effect
of Parkinson's disease on the vision. It is very important that an eye
doctor be involved in the care of the patient with Parkinson's disease and
vision problems.

AH Moderator: The doctors keep referring to the elderly with PD. What about
those of us under 60?

Dr. M Stacy: PD is not a disease of the elderly. In fact, 800 patients per
year in the United States are diagnosed with PD who are under age 40.
Parkinsonologists approach the treatment of PD as a 30+ year illness.
Therefore it is important to consider mobility not only today, but mobility
several decades from today when instituting any therapy.

AH Moderator: For patients that are age 45 and younger, do you feel that
the disease has a faster progression?

Dr. K Sethi: Patients who are diagnosed with PD under the age of 45 are at
higher risk to develop complications related to Sinemet therapy. They may
manifest a variety of abnormal movements which can be quite distressful.
However, they are less likely to develop problems with memory and thinking
as compared with elderly patients. There is no evidence to suggest that the
disease progresses faster in the younger patients. It is important to
approach their treatment differently than that of elderly patients. The
considerations include using a dopamine agonist as opposed to Sinemet, and
using surgical approaches like deep brain stimulation relatively early.

AH Moderator: I'm scheduled for my first consult with a neurosurgeon and
I'm really scared. I love life. Is it worth the risk? Can you tell me about
the surgical approach to PD?

Dr. M Stacy: A referral of a Parkinson's patient to a neurosurgeon from a
parkinsonologist is done with great concern regarding the potential for
complications in that surgery. Many times a parkinsonologist has a
long-term relationship with that patient, and this further amplifies both
doctor and patient anxiety. With that said, the potential risk from
surgical therapy with a thalamotomy or pallidotomy has been 2% in all
centers. Many neurologists and surgeons believe stimulator electrode
implantation in DBS surgery is less traumatic, and therefore safer. As a
patient, it is important to discuss the indications and potential for
benefit with your neurologist and to discuss potential complications with
your neurosurgeon. Along with that information, every potential surgery
patient should be able to discuss this procedure with a patient who has
previously undergone this treatment.

AH Moderator: I have found that many folks are experiencing significant
weight gain after taking Mirapex - have you seen it?

Dr. K Sethi: There are reports of patients bloating up on Mirapex. Weight
gain in PD patients sometimes is a blessing because they tend to lose
weight excessively in spite of taking adequate nutrition. Some drugs like
Symmetrel may cause fluid retention and weight gain. It is a good idea to
attempt to switch to another drug if you are experiencing weight gain on
Mirapex. It is not necessary to stop your drugs completely before starting
a new drug. You can also start the new drug at a higher dose than that
which is usually recommended in a new patient. You should discuss your
specific situations with your doctors.

AH Moderator: Do you think physical therapy (PT) is helpful, and what types
of exercises are safe with patients with PD?

Dr. M Stacy: I feel so strongly about exercise that I'm going to do it
myself someday! This, in essence, represents the biggest barrier to
physical therapy in PD. Because of financial limitations, unlimited
physical therapy is no longer possible. Therefore, a referral for PT must
be treated as a one-month time to learn proper exercises so that they may
be continued at home. There is no question that a Parkinson's patient who
regularly exercises, and performs the exercises suggested by a physical
therapist, will maintain ambulatory ability longer. Indications for a PT
referral include recent falling, a change in posture, or a change in
medication, and usually these are covered by insurance plans.

AH Moderator: How close are we to finding the causes and the cure?

Dr. K Sethi: We are in a very exciting era in the field of PD. A lot of
research is being done to try and diagnose the disease precisely, to slow
down its progression, and ultimately cure it. It is very difficult to
predict when a scientific breakthrough will occur to enable us to cure this
dreadful disease. However, it is hoped that we will be able to slow down
the progression of the disease in the near future. We certainly will be
able to treat symptoms more effectively by using a combination of drugs and
surgical approaches. Transplantation procedures and gene therapy are being
extensively investigated and may someday provide a cure for Parkinson's
disease.

Dr. M Stacy: It looks like our time is about up for tonight and I'd like to
thank Dr. Sethi and all the participants for a great two hours!

Dr. K Sethi: I enjoyed chatting with you and apologize to those of you
whose questions could not be answered for lack of time.

AH Moderator: Thanks to everyone for attending our chat this evening.
Please remember to visit the WE MOVE Web site at http://www.WEMOVE.org. We
invite you to come back to review the transcript of this event, which will
be posted here and on the WE MOVE Web site. Please also look there for
future chat announcements. At the WE MOVE Web site, you can also sign up
for E-MOVE, our free e-mail news service of new research developments in
Parkinson's disease and other movement disorders. We invite you to visit us
soon at www.wemove.org.

AH Moderator: Thank you and goodnight! :)
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WE MOVE - Parkinson's Disease - Web Chat Transcript 9/30/1999
<http://www.wemove.org:/par_pdwc9_30_99.html>