>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