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Dear Bonnie, Thanks very much for your detailed 12 Aug 1998 response to my questions regarding guidelines. I did not initially bring these questions to Aliza's neurologist for the following reasons: I expected to get a more rapid and informative response by posing the questions on this list than if I called or wrote to Aliza's Neurologist.Within hours,Ron Vetter sent us guidelines from Roche,Bob Cowan sent very useful info,then your excellent response, and Brian Collins' enlightening insights.Now we have information to ask him intelligent questions.There is an additional problem here for us,since Tasmar has not yet been approved for use here in Israel.Thus our primary care physician doesn't want any part of it.Thus any recommended tests to check for contra-indications such as liver tests have to be handled through Aliza's neurologist who prescribed the Tasmar whereas normally tests are ordered through her readily-accessible primary care physician. Re my first question about taking Tasmar simultaneously with Sinemet CR,Aliza's neurologist did not give us guidelines at all when he first prescribed taking two pills to start and then going to three.Since she was taking Sinemet CR at 5 hour intervals,it seemed logical to synchronize the Tasmar with the Sinemet and therefore take them together.At the second meeting, after taking the Tasmar for about four weeks,and noting that there was really no noticeable improvement except for apparently sleeping better,he suggested taking six pills per day.When I asked about taking it with the Sinemet CR 5 times a day ,he agreed without comment.After two days of doing this Aliza began to feel shaky after about three hours.We thought two things: 1.The Tasmar is not making the levadopa last six hours. 2.Perhaps,there was an overdosage. We did not associate Aliza feeling shaky with diskinesia which up till now she has not felt. Since yesterday morning,she is taking Tasmar with her 7:00AM Sinemet CR and then at 1:00PM and 7:00PM and felt better in the afternoon which supports the overdose hypothesis. However,last night,she slept very poorly. Re my second question on how one knows to reduce Sinemet CR and/or Sinemet when taking Tasmar, Aliza does not have ON/OFF times per se.Her major symptoms are Bradykinesia(slowness) and poor balance all the time.Her Neurologist did not suggest any reductions.Based on the Roche guidelines, she should not, since she is well below 600mg of effective levadopa per day. Re my third question on when one knows the Tasmar dosage is too much or too little,it would be helpful to have a detailed list of what side-effects to look for. Re my fourth question of the best times to take three Tasmar pills,the Roche guidelines clearly state a six hour interval with the first pill of the day with the Sinemet. What do you mean by "GENERAL" information?What can we expect the doctor to say?He scarcely knows Aliza and does not have any magic information up his sleeve. Re my fifth question re when to take six pills,the Roche guideline is to take two pills together at six hour intervals.This means in Aliza's case that she does not have the benefit of the Tasmar from 1AM to 7AM assuming its benefit lasts six hours.It is not clear why this should be better than spreading the six pills over four hour intervals around the clock. Re my sixth question,as to how long a Tasmar pill lasts,the conclusion that it remains in the system 4-6 hours based on a half-life of 2-3 hours assumes a linear decay in the system. It is interesting that if the decay was exponential,then if the half-life is 3 hours,then after six hours there would still be a quarter left rather than nothing left as predicted by the linear assumption.After 12 hours,there would still be one sixteenth left.So the linear decay is very significant in avoiding cumulative effects due to successive pills. Re my seventh question,as to what PD symptoms are most commonly helped,it would be interesting to know which specific symptoms are helped by enhancing Sinemet and which are not.Aliza's Neurologist told us that her slowness and loss of balance are not promising symptoms to be helped.So maybe her use of Tasmar is a wasted expensive effort. Re my eighth question,as to common over-dosage effects,it would be helpful to have a more comprehensive list of over-dosage effects than those you mentioned.What lead us to think Aliza was over-dosed with five Tasmar pills was her feeling shaky/jumpy.Is this a reasonable effect?Such a feeling could be due to a variety of drug interactions,for example.In Aliza's case, she is taking 11 different drugs. Bonnie,your responses to my questions are very helpful. We will try to develop an "open-line" with Aliza's new neurologist as you suggested. I was already rebuffed once by him for taking up too much of his time. I sent him faxes which his office didn't give him. But he did promise to provide answers to written questions. Because of the problem of accessibility,we are considering switching to another PD specialist who has a nurse and social worker available for patient support. Thanks again. Gil Lieberman,CG for Aliza