This is the second and last part of the City of Hope Parkinson's Newsletter on Medications Used in Parkinson's Disease. ================================================== 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. Start Part II =================================================== MEDICATIONS AND OTHER AGENTS OCCASIONALLY USED TO TREAT ASSOCIATED PROBLEMS OF PARKINSON'S DISEASE BETA BLOCKERS INDERAL (PROPRANOLOL), TENORMIN (ATENOLOL) AND OTHERS Beta blockers are of no direct value in the treatment of Parkinson's symptoms and may occasionally limit levodopa effectiveness. Some patients with Parkinson's, however, have an action or intention tremor brought on by elevation or movement of their arms and which is different from their usual rest tremor. This tremor can at times be reduced in severity by the use of beta blockers. SIDE EFFECTS OF BETA BLOCKERS + Fatigue, nausea and vivid dreaming + Occasional reports of increased forgetfulness + Wheezing, difficulty breathing, fatigue CONTRAINDICATIONS Patients with a history of congestive heart failure, slow heart rate, asthma, bronchitis or emphysema; and people with diabetes who are taking insulin usually should not take beta blockers. Patients on this class of medication should know how to take their own pulse and should contact their physicians if their pulse rate falls below 50-60 beats per minute. SELECTIVE SEROTONIN RE-UPTAKE INHIBITORS (SSRI) ANTIDEPRESSANTS PROZAC (FLUOXETINE), ZOLOFT (SERTRALINE), PAXIL (PAROXETINE) AND OTHERS Depression is more common in Parkinson's disease than in other chronic illnesses of similar severity, probably due to an alteration of neurotransmitter levels in the brain, including the levels of serotonin and norepinephrine. Depression in the Parkinson's patient can worsen virtually all symptoms of the disorder, which in turn can deepen the patient's depression, causing a vicious circle of physical and mental impairment. Often, in order for a patient to get maximal benefit from anti-parkinsonian medications, the depression must be treated. The selective serotonin re-uptake inhibitors (SSRI) antidepressants appear to work by raising serotonin levels in the brain. While they cause few of the side effects associated with the older generation antidepressants, they are much more expensive. Parkinsonian signs often improve following treatment with SSRI antidepressants as depression resolves. In selected patients, SSRI antidepressants may have a more direct effect in relieving certain symptoms of Parkinson's disease by potentiating the effects of dopamine. SIDE EFFECTS OF SSRI ANTIDEPRESSANTS + Nausea, diarrhea, headache, sleepiness, loss of appetite, fatigue and problems having an ejaculation + Prozac and to a lesser degree Zoloft, can cause tremor, insomnia and anxiety. + If taken in the morning, Paxil and Zoloft can cause excessive sleepiness. + Note: On occasion these medications can actually worsen the symptoms of Parkinson's disease or cause a sense of physical restlessness. CONTRAINDICATIONS When combined with Eldepryl (selegiline), these medications 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 these medications and Eldepryl should be discussed with your physician. OTHER ANTIDEPRESSANT MEDICATIONS TRICYCLIC ANTIDEPRESSANTS: E.G., ELAVIL (AMITRYPTYLINE), PAMELOR (NORTRIPTYLINE), NORPRAMIN (DESIPRAMINE), TOFRANIL (IMIPRAMINE) OTHER TYPES OF ANTIDEPRESSANTS: E.G., WELLBUTRIN (BUPROPRION), DESYREL (TRAZADONE) Most of these antidepressant medications have been available for many years and are as effective in the treatment of depression as the SSRI antidepressants They tend to be less expensive, but usually have more side effects. SIDE EFFECTS OF ANTIDEPRESSANT MEDICATIONS + Dryness of the mouth, blurring of near vision, constipation, urinary hesitancy and retention (especially in men) + Abnormal heart rhythms, low blood pressure, upon standing causing symptoms of lightheadedness, excessive sedation or sleepiness and weight gain + Impaired memory function, especially in older patients or those who are already having problems with mental clarity + Confusion and sleepiness which can contribute to walking imbalance and, therefore, to falls SIDE EFFECTS OF SPECIFIC ANTIDEPRESSANT MEDICATIONS + Wellbutrin (buproprion)-seizures + Desyrel (trazadone)--sleepiness, abnormally prolonged erections. CONTRAINDICATIONS Patients who have certain types of glaucoma, who have severe problems with urination or urinary retention, or who have moderate problems of forgetfulness or dizziness due to low blood pressure, should in most instances not take tricyclic antidepressant medications. When combined with Eldepryl (selegiline), these medications can rarely 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 these medications and Eldepryl should be carefully discussed with your physician. ANTI-ANXIETY AND SLEEPING MEDICATIONS ANTI-ANXIETY: E.G., VALIUM (DIAZEPAM), ATIVAN (LORAZEPAM), KLONOPIN (CLONAZEPAM), BUSPAR (BUSPIRONE) SLEEPING MEDICATIONS: E.G., HALCION (TRIAZOLAM), AMBIEN (ZOLPIDEM) All of these medications are classified as sedative-hypnotic agents and can be beneficial in reducing anxiety and promoting sleep. Since some Parkinson's symptoms can be worsened by anxiety, these medications can help relieve symptoms such as tremor and dyskinesia. Klonopin appears to have some unique characteristics and has been used in the treatment of several abnormal movement types. Buspar has been used to treat dyskinesias with variable success. SIDE EFFECTS OF ANTI-ANXIETY AND SLEEPING MEDICATIONS + Sedation (excessive sleepiness): This can interfere with one's ability to operate machinery, such as a motor vehicle and contribute to waling imbalance and falls. + Occasionally, patients can become psychologically, as well as physically, dependent upon these medications and experience withdrawal symptoms upon their discontinuation. + Patients who depend upon these medications to sleep can have aftereffects lasting into the next day, which can impair memory and other thinking functions. Under these conditions, patients may have greater problems with walking balance and be more susceptible to falls. + Buspar (buspirone) appears to have a lower risk of physical and psychological dependence, but some patients may experience a worsening of Parkinson's symptoms. MEDICATIONS TO TREAT CONFUSION (MAJOR TRANQUILIZERS) TYPICAL TRANQUILIZERS E.G., THORAZINE (CHLORPROMAZINE), HALDOL (HALOPERIDOL), MELLARIL (THIORIDAZINE), RISPERDAL (RISPERIDONE) ANTI-NAUSEA, ANTI-EMETIC AGENTS: E.G., COMPOZINE (PROCHLORPERAZINE), TIGAN, PHENERGAN These medications, which sometimes are referred to as "neuroleptics," are used to treat various psychiatric problems such as confusion, frightening hallucinations and delusions. They can also be useful in treating problems of nausea and vomiting. In general, they are contraindicated for the Parkinson's patient since they may severely worsen the symptoms of Parkinson's disease. Even in persons who do not have Parkinson's, the prolonged use of neuroleptics has been associated with "drug induced" or symptomatic Parkinson's. ATYPICAL TRANQUILIZERS CLOZARIL (CLOZAPINE) Clozaril appears to be unique in that it can help relieve the symptoms of confusion and hallucinations without significantly worsening the symptoms of Parkinson's in most patients. It has also been used to treat a number of movement problems associated with Parkinson's such as severe dyskinesias. SIDE EFFECTS OF CLOZARIL + Sedation (excessive sleepiness): a drop in blood pressure on standing, causing faintness; and hypersalivation with increased drooling + Seizures: generally at higher doses than those used in Parkinson's patients + Severe lowering of white blood cell count (agranulocytosis), which can compromise a person's ability to fight infection and has led to a number of deaths in patients treated with Clozaril. For this reason, weekly blood counts must be taken on all patients receiving Clozaril and no patient may receive more than a one week's supply of medication at a time. SOME OTHER MEDICATIONS USED IN PARKINSON'S PATIENTS LODOSYN (CARBIDOPA) Upon first taking Sinemet (levodopa / carbidopa), some patients experience nausea and vomiting. For some, this problem can persist for months and prevent them from taking Sinemet as prescribed. By taking supplemental carbidopa pills, this problem can sometimes be effectively controlled. MOTILIUM (DOMPERIDONE) This medication has not been approved by the Food and Drug Administration and is not available by prescription within the United States. It is, however, available in many European countries, Mexico and Canada. Its primary value for the Parkinson's patient is in preventing levodopa-associated nausea and vomiting when extra carbidopa is ineffective. Preliminary studies would suggest that this is generally a safe medication and one that is well tolerated by patients. ZOFRAN (ONDANSETRON) This is a very expensive medication that is primarily used with cancer chemotherapy to prevent nausea. There are several brief reports of its value in relieving confusion, hallucinations and delusions in Parkinson's patients. In general, this medication is very well tolerated, with the major side effects being headaches, diarrhea and fatigue. The high cost of this medication, however, is frequently a prohibitive factor for treatment. HYDERGINE (COMBINATION OF ERGOLOID MESYLATES) This agent was introduced many years ago for the treatment of senile dementia. Despite years of study, there is still controversy whether Hydergine improves thinking abilities and /or behavior in those with dementia: Some of the agents contained in Hydergine have dopamine agonist properties and have been shown in both human and animal studies to have anti-parkinsonian effects. The doses used in these studies are, however, many times those customary for Hydergine use in medical treatment. Even at high doses, the ergoloid mesylates have not been directly compared to available dopamine agonists, such as pergolide, to see if they have any special advantages. Hydergine and its related compounds are. claimed to have anti-oxidant properties, but the clinical significance of these effects is unknown. Side effects of treatment include nausea, stomach upset, headache and low blood pressure. At high dose, these agents may also be associated with spasm of the blood vessels in the arms or legs. BOTOX (BOTULINUM TOXIN A) This is one of the most potent biological toxins known to man. When injected into a muscle, botulinum toxin poisons nerve endings, causing muscle weakening and wasting, which can persist for several months. Some patients with Parkinson-related dystonia can have the severity of their dystonia reduced by receiving injections into the dystonic muscles. Treatment with this agent, however, is very expensive. FLORINEF (FLUDROCORTISONE ACETATE) This is the most commonly used medication to treat symptoms of orthostatic hypotension, which is a severe drop in blood pressure caused by standing. Florinef causes the body to hold onto salt and water and can increase the volume of fluid within the circulatory system. Ankle swelling and weight gain are expected side effects of treatment. Persons receiving Florinef should cautiously increase their salt intake to enhance its actions. Potassium supplements are additionally indicated in many patients to prevent potassium levels from falling dangerously low. Patients taking Florinef should record their weights on a daily basis, particularly when this medication is first started, or when doses are raised. Note: Florinef used with caution when there is a history of heart disease since it can cause congestive heart failure and high blood pressure when one is lying down. DDAVP (DESMOPRESSIN) Available in nose-spray and nose-drop preparations, this hormone analogue decreases the production of urine. It has been approved as a means of preventing bed wetting in children. When taken as a single dose at night, it may help Parkinson's patients who have severely reduced bed mobility, by decreasing their need to urinate at night. Due to water retention, Desmopressin may cause severe electrolyte disturbances and high blood pressure and its use must therefore be carefully monitored. LIORESAL (BACLOFEN) This medication is primarily used to reduce spasticity. It is also of benefit in patients with certain forms of dystonia. When taken at night it may help reduce painful ankle dystonia and muscle cramps which are experienced by some Parkinson's patients at night or upon awakening in the morning. Potential side effects include sleepiness, a sense of generalized weakness and fatigue and confusion. STIMULANTS CYLERT (PEMOLINE), RITALIN (METHYLPHENIDATE), DEXEDRINE (DEXTROAMPHETAMINE), CAFFEINE AND OTHERS Stimulants are occasionally used to offset the sedative effects of levodopa and other Parkinson's medications and may additionally have mild anti-depressant and analgesic effects. Ritalin and Dexedrine are tightly controlled and require special prescriptions. SIDE EFFECTS OF STIMULANTS Weight loss, agitation, insomnia, palpitations, anxiety, physical and psychological dependence CONTRAINDICATIONS Patients with advanced heart disease, hyperthyroidism, or a history of drug dependency should not take stimulants. PROPULSID (CISAPRIDE) Propulsid increase the motility or contractions of the stomach, allowing food and medications to pass more quickly from the stomach into the small intestine. Some Parkinson's patients have difficulty with stomach emptying, which in turn can cause a delay in the absorption of levodopa. Propulsid may help make drug absorption quicker and more predictable in such patients. Reglan (metoclopramide) has similar actions, but may cause confusion and worsen Parkinson's symptoms. For these reasons, its use is contraindicated in Parkinson's disease. Propulsid has also been used in the treatment of constipation, with variable success. Some Parkinson's patients have recently been reported to have increased tremor while taking Propulsid. ANTIOXIDANT VITAMINS VITAMIN C-ASCORBIC ACID, VITAMIN E, BETA-CAROTENE Knowledge is rapidly evolving on the importance of antioxidant agents in laboratory animal models of Parkinson's disease. It is hoped that the use of antioxidant agents can slow the progression of Parkinson's disease and, in some instances, improve related symptoms. To date, however, there is no large, well-controlled study indicating any benefit of antioxidant vitamins for Parkinson's patients. Generally, the vitamins listed above are safe, though high doses of Vitamin C have been associated with stomach upset and kidney stones. LAXATIVES AND STOOL SOFTENERS Chronic constipation can cause considerable discomfort for Parkinson's patients. In some patients, inadequately treated constipation can contribute to loss of appetite and weight loss, inactivity, fatigue, discouragement and even confusion. Others can experience problems associated with unpredictable medication absorption such as unpredictable dyskinesias and "off" periods. Various over-the-counter and prescription medications are available to treat this problem. Your doctor can help you develop a sensible and effective bowel regimen. MELATONIN Melatonin is a natural hormone produced by the pineal gland of the brain. It has been promoted as a sleep-inducing aid and has traditionally been available through various health food stores. There is still considerable question whether melatonin is safe and effective in the treatment of insomnia or for use as an antioxidant. Some scientists question the safety, purity and potency of unregulated off-the-shelf melatonin purchased through health food stores. There are concerns that unanticipated adverse effects or contaminants can cause serious toxicity. Comparisons have been made to tryptophan, an amino acid which until recently was also sold as a sleeping aid in health food stores. Tryptophan was taken off the market after nearly 40 people died and hundreds were disabled following its use. DRUG INTERACTIONS There are many real and potential drug interactions with new interactions recognized on an ongoing basis. The following list, while incomplete, highlights several drugs that could have potentially significant interactions. Also see Appendix B and C for a list of drugs that may be contraindicated in Parkinson's disease. + Prozac, Paxil, Zoloft and other Serotonin Enhancing Medications and Eldepryl (see "Serotonin Syndrome" in Eldepryl section). + Demerol and Eldepryl APPENDIX A CITY OF HOPE NATIONAL MEDICAL CENTER CITY OF HOPE City of Hope is comprised of City of Hope National Medical Center and Beckman Research Institute, both of which are located on a 100-acre campus in Duarte, California. Founded in 1913, City of Hope is a Clinical Cancer Research Center, a designation it received from the National Cancer Institute in 1981. For the past 82 years, City of Hope has employed the expertise of health care professionals and scientists who are the finest in their fields and who are committed to working together to provide the latest advances in clinical care and to conduct innovative basic research into cancer as well as other major diseases such as diabetes. Through their collaboration, these professionals are committed to furthering City of Hope's dedication to providing compassionate, quality care. CITY OF HOPE PARKINSON'S CLINIC NEW PATIENT REFERRAL INFORMATION Those wishing to make an appointment at the City of Hope Parkinson's Clinic may do so by contacting the City of Hope Patient Referral Department at (818) 359-8111, Ext. 3292. All patients are encouraged to bring copies of pertinent medical records including brain MRI or CT scans to their appointments. Health maintenance organization (HMO) patients who do not have prior authorization from their HMO can be seen on a second-opinion basis. NATIONAL PARKINSON'S FOUNDATION (NPF) Founded in 1957, NPF is headquartered at the University of Miami, where it supports a multidisciplinary Parkinson's treatment and research program. In addition, NPF funds 31 Research Centers of Excellence located in prestigious medical institutions around the world. During 1995, NPF has added several more Research Centers of Excellence and a number of newly designated Clinical Centers of Excellence, including one at City of Hope National Medical Center. Many of the Research Centers and all of the Clinical Centers provide diverse services for patients and their families, including diagnosis, treatment, educational services, information and referrals and the sponsorship of support groups in neighboring areas. In addition to its headquarters in Miami, NPF also has an office in Encino, California. Questions about NPF can be directed to Mary Willis, City of Hope, NPF Parkinson's Coordinator (818-301-8985) or to Kim Seidman, NPF West Coast Director (800-400-8448). APPENDIX B MEDICATIONS TO BE AVOIDED OR USED WITH CAUTIAN BY PARKINSON'S PATIENTS LISTED BY MEDICATION TYPE Medication Type Brand Name Generic Name Risk Factor Analgesic Demerol Meperidine High* Anti-Anxiety Buspar Buspirone Low Anti-Vomiting Compazine Prochlorperazine High Anti-Vomiting Reglan Metoclopramide High Anti-Vomiting Tigan Trimethobenzamide Moderate Anti-Vomiting Torecan Triethylperazine High Antidepressant Ascendin Amoxapine Moderate Antidepressant Nardil Phenelzine High Antidepressant Parnate Tranylcypromine High Antidepressant Paxil Paroxetine Low Antidepressant Prozac Fluoxetine Low Antidepressant TriaviI Perphenazine** High Antidepressant Zoloft Sertraline Low Antipsychotic Haldol Haloperidol High Antipsychotic Loxitane Loxapine High Antipsychotic Mellaril Thioridazine Moderate Antipsychotic Moban Molindone Moderate Antipsychotic Navane Thiothixene High Antipsychotic Orap Pimozide High Antipsychotic Permitil Fluphenazine High Antipsychotic Prolixin Fluphenazine High Antipsychotic Risperdol Risperidone Moderate Antipsychotic Stelazine Trifluoperazine High Antipsychotic Trilafon Perphenazine High Antipsyehotic Thorazine Chlorpromazine High Blood Pressure Aldomet Alpha-methyldopa Low Blood Pressure Cardizem Diltiazem Low Blood Pressure Catapres Clonidine Low Blood Pressure Demi-Regroton Reserpine High Blood Pressure Diupres Reserpine** High Blood Pressure Enduronyl Deserpidine** High Blood Pressure Harmonyl Deserpidine High Blood Pressure Hydropres Reserpine** High Blood Pressure Oreticyl Deserpidine High Blood Pressure Raudixin Rauwolfia S. High Blood Pressure Rauzide Rauwolfia S.** High Blood Pressure Regroton Reserpine High Blood Pressure Salutensin Reserpine High Blood Pressure Ser-Ap-Es Reserpine High Manic Depression Lithobid Lithium Low * If taking Eldepryl ** Constituent product APPENDIX C MEDICATIONS TO BE AVOIDED OR USED WITH CAUTIAN BY PARKINSON'S PATIENTS LISTED BY BRAND NAME OF MEDICATION Brand Name Generic Name Medication Type Risk Factor Aldomet Alpha-methyldopa Blood Pressure Low Ascendin Amoxapine Antidepressant Moderate Buspar Buspirone Anti-Anxiety Low Cardizem Diltiazem Blood Pressure Low Catapres Clonidine Blood Pressure Low Compazine Prochlorperazine Anti-Vomiting High Demerol Meperidine Analgesic High* Demi-Regroton Reserpine Blood Pressure High Diupres Reserpine** Blood Pressure High Enduronyl Deserpidine** Blood Pressure High Haldol Haloperidol Antipsychotic High Harmonyl Deserpidine Blood Pressure High Hydropres Reserpine** Blood Pressure High Lithobid Lithium Manic Depression Low Loxitane Loxapine Antipsychotic High Mellaril Thioridazine Antipsychotic Moderate Moban Molindone Antipsychotic Moderate Nardil Phenelzine Antidepressant High Navane Thiothixene Antipsychotic High Orap Pimozide Antipsychotic High Oreticyl Deserpidine Blood Pressure High Parnate Tranylcypromine Antidepressant High Paxil Paroxetine Antidepressant Low Permitil Fluphenazine Antipsychotic High Prolixin Fluphenazine Antipsychotic High Prozac Fluoxetine Antidepressant Low Raudixin Rauwolfia S. Blood Pressure High Rauzide Rauwolfia S.** Blood Pressure High Reglan Metoclopramide Anti-Vomiting High Regroton Reserpine Blood Pressure High Risperdol Risperidone Antipsychotic Moderate Salutensin Reserpine Blood Pressure High Ser-Ap-Es Reserpine Blood Pressure High Stelazine Trifluoperazine Antipsychotic High Thorazine Chlorpromazine Antipsyehotic High Tigan Trimethobenzamide Anti-Vomiting Moderate Torecan Triethylperazine Anti-Vomiting High TriaviI Perphenazine** Antidepressant High Trilafon Perphenazine Antipsychotic High Zoloft Sertraline Antidepressant Low * If taking Eldepryl ** Constituent Product ================================================ End Part II - End of Material Note: Appendix B and C are four columns of data. Between each column is a <tab>. This should allow for easy formating. The first row is the header row. Regards, Alan Bonander ([log in to unmask])