Fairlee, Here is some information about the new medications alleged to be released this year for PD, including ropinirole. I hope this is useful....Carole >Up And Coming Medical Therapies for Parkinson's Disease > >by Matthias C. Kurth, MD, Ph.D., Medical Director and Advisor for >Young Parkinsonians and the US NPR YOPPERS FORUM > > The coming year will bring new and exciting treatment >options for Parkinson's disease patients. Four new drugs, all shown >to improve patients' symptoms, are expected to be approved by the >Federal Drug Administration (FDA). Each drug offers unique >advantages that will greatly increase patient and physician choices >in developing a therapeutic program to minimize the impact of >Parkinson's disease throughout the day. These agents will be >particularly useful for young onset patients since two of >them may offer some element of neuroprotection and all four >agents will enhance patients' well-being by improving symptom >control. In preparation for the release of these agents, a review >of their properties, mechanisms of action and results of clinical >trials is in order. This knowledge will empower patients and >physicians to combine the appropriate medications for optimal >control of parkinsonian symptoms. > >Catechol-O-Methyl Transferase Inhibitors > > One new approach to treating Parkinson's disease involves >prolonging the action of levodopa by inhibiting the enzyme catechol- >o-methyltransferase (COMT) involved in the metabolism of levodopa >and dopamine. inhibition of this enzyme in the body decreases the >concentration of a levodopa metabolite, 3-0-methyldopa, which may >have a role in inducing or aggravating levodopa response >fluctuations. More importantly, blood levels of levodopa are >maintained for a longer time and patients experience a smoother, >more beneficial effect from each dose of levodopa. > >Tolcapone (Tasmar(r), Hoffman-LaRoche) > > Tolcapone is the most potent COMT inhibitor currently >in clinical development. Studies in patients with Parkinson's >disease in the United States and Europe are complete and have >been submitted to the FDA. Tolcapone prolongs the effects of >levodopa thereby decreasing motor response fluctuations in patients >and improving quality of life. Patients on levodopa that do not >experience motor fluctuations also benefited significantly through >improved quality of life and decreased symptoms. > Tolcapone is given three times daily in doses from 100 mg >to 200 mg in addition to the patient's levodopa medication schedule. >Peak effect of tolcapone is reached in about 1 - 2 hours and >maintained for the duration of the 6 hour dosing interval. >Patients experience better control of their Parkinsonian symptoms >while needing lower doses of levodopa. Side effects are few, but >include occasional mild headache, nausea, loose stools, change >in urine color, and in some patients a transient increase in >dyskinesia. Tolcapone is absorbed by the small intestine and >metabolized by the liver. Food delays the absorption of tolcapone >somewhat, but this does not appear to be clinically significant. >The ability of this compound to prolong blood and brain levels of >levodopa while reducing the levels of potentially toxic metabolites >should be an important development in the treatment of >Parkinson's disease. > >Entacapone (no brandname available. Orion/Farmos and Sandoz) > > Entacapone is another new catechol-o-methyltransferase >inhibitor. Like tolcapone, this compound improves the effectiveness >of levodopa by decreasing fluctuations in medication response >through inhibition of COMT. > Studies to determine long-term safety and benefits of >entacapone as a supplement to levodopa treatment in Parkinson's >disease patients with reduced benefits or complications from >levodopa have been completed in the United States and Europe. >Entacapone enhances the effects of levodopa and is safe. Occasional >mild side effects include headache, dizziness. nausea, loose stools, >increased dyskinesia and changes in the color of urine. > Entacapone is taken with each dose of levodopa. Peak effect >is within one hour and its duration of action closely matches that >of carbidopa/levodopa. These properties suggest that a combination >tablet containing levodopa, carbidopa and entacapone may be feasible >and desirable. Current plans include further studies to determine the >benefit of entacapone in patients taking levodopa, but not >experiencing motor fluctuations. > > Both tolcapone and entacapone are potent COMT inhibitors >that prolong the duration of levodopa activity in patients with >Parkinson's disease. Differences in the side effect profile, >dosing schedule and potency will need to be addressed in comparative >studies. Both tolcapone and entacapone will be valuable adjuncts for >all patients using levodopa therapy. > >New Dopamine Agonists > > As soon as levodopa became available for the treatment of >Parkinson's disease, efforts to find medications that could mimic >it's dramatic effect on the symptoms of Parkinson's disease, but >with fewer side effects, were begun. The result of this search >yielded the well known dopamine agonists bromocriptine (Parlodel(r)) >and pergolide (Permax(r)). Neither met the desired expectation of >fully replacing levodopa. Only the nonspecific dopamine agonist, >apomorphine, has the spectrum of efficacy needed to fully treat >patients in a manner similar to levodopa. Unfortunately, apomorphine >has significant side effects and is difficult to store and administer. >In a significant step towards achieving true levodopa replacement, >two new agents are currently under review by the FDA for use in >patients with early Parkinson's disease. In addition to having >sufficient potency to act as first line therapy, these two drugs >may also have neuroprotective effects that slow disease progression. > >Pramipexole (Mirapex(r), Pharmacia & Upjohn > > Pramipexole is a potent, non-ergot dopamine agonist used >alone in treating patients not yet taking levodopa and as an adjunct >to levodopa in treating advanced Parkinson's disease patients. While >stimulating the dopamine D2-receptor, pramipexole may be effective >in either blocking or selectively not stimulating the D1-receptor, >thereby preventing dyskinesia. More recently, a specific dopamine >D3 receptor activity has been identified and linked to a >neurotrophic effect. In tissue culture models of Parkinson's >disease, pramipexole protected neurons from specific dopaminergic >neurotoxins, while bromocriptine and pergolide had no such effect. >Pramipexole may also delay the need for levodopa and the development of >dyskinesla. End of dose wearing off is reduced in patients with more >advanced disease receiving pramipexole and levodopa. > Patients in the United States, Canada and Europe have been >treated with pramipexole in doses ranging from 0.1 mg to 5 mg daily. >No dose-limiting toxicity was identified. Tolerability and safety were >excellent with only occasional dizziness, nausea, vomiting, insomnia >or somnolence and visual hallucinations identified as primary side >effects. Symptomatic low blood pressure was not a significant side >effect. The half-life of pramipexole is about 9-12 hours, easily >allowing a three times a day schedule. The drug is excreted by the >kidneys so that patients with kidney problems may need to be >monitored closely for side effects. > >Ropinirole (Requip(r), Smith, Kline and Beecham) > > Ropinirole is a potent, highly selective, dopamine agonist, >not related to pramipexole or the ergot derived drugs, developed for >early therapy in Parkinson's disease patients not yet treated with >levodopa and as adjunct therapy in treating Parkinson's disease >patients not optimally controlled on levodopa. This potent D2-dopamine >agonist is active both centrally and peripherally with central >nervous system and cardiovascular activity seen. Antidepressant and >anxiolytic effects have also been noted in patients with >Parkinson's disease. Evidence of a possible neuroprotective effect >has been documented. > More than 300 patients with Parkinson's disease have >completed placebo-controlled studies of ropinirole, taking doses up >to 10 mg daily. Typical dopamineric side effects such as nausea, >vomiting and orthostatic hypotension may occur at doses above 0.5 mg. >Incremental dosage increases minimize these side effects, and the drug >is tolerated extremely well by the majority of patients. A three times >daily dosing schedule of lower doses given with meals allows for fewer >side effects and closer conformance to it's half-life of 3.5-5 hours. > >Cabergoline (no brandname available, Pharmacia & Upjohn) > > Cabergoline, an ergoline derivative related to bromocriptine >and pergolide, is a D2-specific dopaminergic agonist that is more >potent and longer-acting than other dopamine agonists currently used >to treat Parkinson's disease. In patients receiving levodopa, it >effectively decreases levodopa response fluctuations and allows for >lower levodopa doses. Plasma activity peaks between 0.5 and 4 hours >with a half-life of about 7.5 hours and a slower elimination of 68-72 >hours. > Patients in Italy, the United States and Canada have been >treated with cabergoline once daily in dosages from 0.5 to 5.0 mg. >Side effects are typical for dopaminergic agents and can include >dizziness, nausea, dry mouth and orthostatic hypotension. Episodes >of visual hallucinations also occurred in a few patients. The once >daily schedule and long-acting effects offer greater compliance and >provide greater control of motor fluctuations than currently >available dopamine agonists. Unfortunately, this drug may not be >offered as an anti-parkinsonian agent, but instead may only be >marketed as a prolactin suppressing agent to stop lactation. At this >time, no efforts to market this drug for Parkinson's disease are >underway. > > Two new dopamine agonists, chemically different than >currently used agents, are under review at the FDA for possible use >in the treatment of Parkinson's disease. Both agents have >demonstrated benefit in improving symptoms in patients with early >(untreated) and late (levodopa treated) Parkinson's disease. >Differences in benefit profiles, side effects and metabolism >of the drugs will allow patients to find the right medication for >their particular needs. If the potential of neuroprotection is born >out in future studies then these agents will truly be a major advance >in the treatment of Parkinson's disease. A third drug that offered >once a day dosing may never be released for Parkinson's disease >despite evidence of efficacy and safety. > > > The treatment options for patients diagnosed with >Parkinson's disease will be increased significantly with the >introduction of these new medications. Combining the right amount >and frequency of each medication in an individual will be more >complicated in some ways, yet simpler in other ways. One prediction >would be that newly diagnosed patients will begin therapy with >one of the new dopamine agonists. Later such patients might >consider adding one of the older drugs that offers additional hope >of neuroprotection, either amandatine or selegiline. > Another prediction Is that patients already taking levodopa, >either in the form of Sinemet(r) (primarily taken by US patients) >or Madopar(r) (used mainly in Europe), would want to consider addition >of a catechol-o-methyltransferase inhibitor, either tolcapone or >entacapone. Significant improvements in symptom control and reduced >wearing-off can be expected immediately. Both medications, work well >with either regular carbidopa/levodopa and the slow-release >formulation of Sinemet CR(r). Patients with a stable response to >levodopa should experience improvement without needing significant >adjustments in levodopa dosages. Some adjustments might be warranted >in patients with significant levodopa induced dyskinesia or other >dopaminergic side effects. > The introduction of these new medications will make 1997 one >of the most exciting years for advancements in the treatment of >Parkinson's disease. Patients, family members, caregivers, physicians >and health care systems all over the world will benefit, all because >of the diligent application of our rapidly growing understanding of >the functions of the human central nervous system. Given the pace of >progress over the last few years, a true understanding of the cause >and ultimate cure for Parkinson's disease should not be too far in >the future. >John Cottingham To search the Parkinsn archive, send search requests > to [log in to unmask] with Archive Search as the subject. >LibraryH Searches of the Subject: line, From: line and Body are > possible. Look for "Revised Current Topics...." message >HomeBoy for Articles and Studies available by e-mail. > PARKINSONIANS WORLD-WIDE GIVE THANKS IN MEMORY OF ALAN >[log in to unmask] BONANDER.....WHERE EVER YOU ARE! >