Tremor
Parkinson's Disease Management
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Parkinson's Disease Management
, Parkinsonism Management
See Also
Parkinsonism
Thalamic Stimulation
(
Deep Brain Stimulation
)
Carbidopa/Levodopa
(
Sinemet
)
Dopamine Agonist
Management
Consult neurology
Especially for all patients with onset under age 60 years
Adjunctive services
Group support
Disease specific education
Nutrition guidance (
Healthy Diet
)
Avoid
Herbals
and supplements to treat
Parkinsonism
No evidence of benefit (including
Vitamin E
)
Exercise
guidance (consider physical therapy
Consultation
)
Stretching
Strengthening
Balance training
Voice training
Medications
See
Levodopa
See
Dopamine Agonist
See treatment algorithm below
See adjunctive managament below
Surgical management
See
Thalamic Stimulation
(
Deep Brain Stimulation
)
Management
Treatment Algorithm
Precautions
Levodopa
is the most effective agent, but has serious
Extrapyramidal Side Effect
s
Longterm
Levodopa
causes
Dyskinesia
s that may be permanent
Delay starting
Levodopa
until it is indicated (see protocol below)
However, start when there is any impact on activity
No functional deficit (normal ADLs, quality of life)
No medications needed
See
Gene
ral Measures below
Cognitive Changes and Functional
Disability
Conservative use of
Sinemet
No Cognitive changes
No functional
Disability
Consider Selegiline (Eldepryl)
Mild Functional
Disability
with
Tremor
predominant
Consider
Amantadine
Consider
Anticholinergic
s
Trihexyphenidyl HCl (Artane)
Benztropine mesylate (Cogentin)
Moderate to severe functional
Disability
Carbidopa/Levodopa
(
Sinemet
SR)
Consider
Dopamine Agonist
s (see below)
Late Stage
Parkinson's Disease
Characteristics
Dyskinesia
(involuntary
Choreiform
movements)
Early wearing-off effect of
Levodopa
(off-time)
On-Off fluctuations in motor activity
Medication Adjuncts (used in
Consultation
with Neurology)
Inbrija (inhaled
Levodopa
)
Rapid onset (10 min after inhalation) and duration of 1 hour used for prn "off time" rigidity or
Tremor
Less expensive ($30/dose) than Apokyn ($200/dose), an injectable option for off-time
Requires dexterity to replace capsule in
Inhaler
Avoid in underlying lung disease (e.g.
Asthma
,
COPD
) due to bronchospasm risk
(2019) Presc Lett 26(5)
Non-ergot Dopamine Agonist
s (preferred, most effective agents at reducing off-time)
Pramipexole
(
Mirapex
)
Ropinirole
(
Requip
)
Apomorphine
(Apokyn) SQ Injection (
Dopamine Agonist
prn for off-time)
COMT Inhibitors
Entacapone (Comtan)
MAO-B Inhibitors
Selegiline HCL (Eldepryl) 5 mg at breakfast and lunch
Available generically for $90/month
Contrast with Rasagaline for $430, Safinamide for $670
Rasagiline (Azilect) 0.5 mg orally daily (may be increased to 1 mg orally daily)
Safinamide (Xadago) 50 mg orally daily (may be increased to 100 mg orally daily)
Amantadine
Surgery
Deep Brain Stimulation
Management
Adjunctive Medications
Monoamine oxidase Type B inhibitor
Gene
ral
Less effective than
Sinemet
or
Dopamine Agonist
s
Fewer adverse effects including less diskinesia
Preparations
Selegiline HCL (Eldepryl) 5 mg at breakfast and lunch (generic for $90 per month)
Rasagiline (Azilect) 0.5 mg orally daily (may be increased to 1 mg orally daily)
Safinamide (Xadago) 50 mg orally daily (may be increased to 100 mg orally daily)
Anticholinergic Medication
s
Preparations
Trihexyphenidyl HCl (Artane)
Artane 4-10 mg/day divided tid
Benztropine mesylate (Cogentin)
Cogentin 1-4 mg/day divided qd-bid
Adverse effects (limit use to under age 70)
Memory
Impairment
Hallucination
s
Dry Mouth
Urinary difficulty
Blurred vision
Adjunctive Agents (
Vitamin Supplement
ation)
Amantadine
HCL (Symadine,
Symmetrel
)
Decreases
Levodopa
induced motor disorder (only agent to reduce
Dyskinesia
s)
Dyskinesia
reducing effect may be only modest and may last for less than 8 months
Continue long-term
Metman (1999) Arch Neurol 56:1383-6 [PubMed]
Conenzyme Q10
360-1200 mg PO daily
Shults (2002) Arch Neurol 59:1541-50 [PubMed]
COMT Inhibitors
Indications
Late-stage
Parkinson's Disease
Mechanism
Extends
Levodopa
half-life
Agents
Entacapone (Comtan)
Tolcapone (Tasmar) - avoid
Rare lethal hepatotoxicity (closely watch
Liver Function Test
s)
Management
Miscellaneous non-motor conditions
Constipation
Increase fluids and fiber
Wean
Anticholinergic
s
Consider polyethylene gylcol (
Miralax
) and enemas as needed
Major Depression
Cognitive
Impairment
(
Dementia
)
Present in 60% of
Parkinsonism
patients by 12 years from
Parkinsonism
onset
Wean any
Anticholinergic
s
Consider
Cholinesterase Inhibitor
s (e.g.
Aricept
)
Dysphagia
Swallowing evaluation
Use adjuncts to extend medication active time
Eat during "on" time and stick to soft foods
Drooling
Glycopyrolate
Botox
Urine urgency
Consider
Oxybutynin
(
Ditropan
)
Psychosis
or
Hallucination
s
Wean
Anticholinergic
s,
Dopamine Agonist
s (e.g.
Amantadine
, benztropine, selegeline)
Decrease
Levodopa
dosing
Consider low dose
Antipsychotic
s
Clozapine
(
Clozaril
)
Quetiapine
(
Seroquel
) 12.5 mg daily
Avoid harmful agents
Avoid Nuplazid (pimavanserin,
Serotonin
-selective agent) until further study
Expensive with potential for serious adverse effects
http://www.fiercebiotech.com/regulatory/updated-fda-s-internal-review-of-acadia-s-parkinson-s-drug-raises-safety-benefit
Avoid
Zyprexa
Ineffective for
Psychosis
in
Parkinsonism
Exacerbates motor symptoms
Avoid
Haloperidol
Exacerbates motor symptoms, and adverse effects may be severe
Fatigue
(one-third of
Parkinsonism
patients)
Carbidopa-Levodopa
is associated with less
Fatigue
Methylphenidate
(
Ritalin
) may improve
Fatigue
Sleep
disturbance
Daytime somniolence (>50% of
Parkinsonism
patients)
Stop
Dopamine Agonist
s
Melatonin
is NOT effective in
Parkinsonism
Modafinil
(
Provigil
)
Do not use to prevent sleep attacks
Sleep
attacks
Do not perform hazardous duties
Do not drive
Do not operate machinery
Awakens from
Bradykinesia
Sinemet
before bed or
COMT Inhibitor or
Dopamine Agonist
REM Sleep Behavior Disorder
Presents with dramatic and sometimes violent activity during sleep (yelling, kicking, jumping)
Decrease nighttime anti-parkinson drug dose and
Consider
Clonazepam
(
Klonopin
)
Restless Leg Syndrome
See
Restless Leg Syndrome
for management
References
Ahlskog (2011) Mayo Internal Medicine Review Lecture
Schim (2001) CMEA Medicine Lecture, San Diego
Clarke (2003) Clin Evid 10:1582-98 [PubMed]
Clarke (2004) Lancet Neurol 3:466-74 [PubMed]
Gazewood (2013) Am Fam Physician 87(4): 267-73 [PubMed]
Nutt (2005) N Engl J Med 353:1021-7 [PubMed]
Olanow (2001) Neurology 56:S1-88 [PubMed]
Rao (2006) Am Fam Physician 74:2046-56 [PubMed]
Young (1999) Am Fam Physician 59(8):2155-67 [PubMed]
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