Date: Fri, 24 Nov 1995 02:23:06 -0500
From: [log in to unmask]
Subject: Medications in PD - II
^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
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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 Modera
Buspirone Buspar 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 Low
* If taking Eldepryl ** Constituent Product
End Part II - End of Material
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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])
-----------------------------------------------------------------------------
Transmitted by Margaret Tuchman
"It's better to be healthy, wise, rich and beautiful then to be sick,
dumb, poor and ugly"
Lily Tomlin monologue about life and love.
And she says, "remember--we're all in this alone."
.
