Enhancing Healthcare Team Outcomes
Anticholinergic medications are quite prevalent throughout the healthcare system, and many drugs that are not used explicitly for their anticholinergic properties still have anticholinergic side effects. The entire interprofessional healthcare team, including all clinicians , nurses, and pharmacists, need to be well-versed in both the therapeutic and adverse properties of anticholinergic drugs. This is most important regarding the contribution of anticholinergics to adverse events. The team should monitor the overall anticholinergic burden, attempt to limit unnecessary use of anticholinergic medications, and pay special attention to high-risk groups such as the elderly and those receiving treatment for depression and schizophrenia.
Anticholinergics In Clinical Trials For Parkinsons Disease
Several studies have shown that anticholinergics are useful in reducing tremors. Two studies, one published in Movement Disorders and the other in Archives of Neurology, found that anticholinergics, as well as dopamine agonists , are effective at reducing tremors in Parkinsons disease. Some patients responded better to one treatment than the other.
Studies have also shown, however, that anticholinergics may be associated with greater cognitive decline in Parkinsons patients. A meta-analysis study showed that anticholinergics lead to a definite improvement in motor symptoms but are also associated with side effects including cognitive decline and hallucinations. The study analyzed six anticholinergics but did not have enough evidence to compare their efficacy.
What Future Medications May Be Available For Parkinsons
There are numerous studies investigating new treatments for Parkinsons disease.
There has been new information about the role of autoimmunity and T-cells in the development of Parkinsons disease, possibly opening the door to a role for biologics.
Stem cells are also being investigated as a treatment option for Parkinsons disease.
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Treating Depression In Parkinsons Disease
Depression in people with Parkinsons is still under-recognized and under-treated, Richard tells WebMD.
As doctors have become more aware of how common it is, she says, they have struggled with how best to treat it.
Older antidepressants known as tricyclic antidepressants are sometimes used, she says. But their use is linked with certain types of heart problems and other side effects.
Richards team studied paroxetine and venlafaxine extended release , comparing it to placebo.
Paroxetine is an SSRI , which affects levels of the hormone serotonin in the brain, improving mood.
Venlafaxine extended release is an SNRI . It works by balancing the two hormones to improve mood.
The 115 patients all had both Parkinsons and clinical depression. Patients had to be at least 30 years old and free of dementia. They were treated at 20 different centers in the U.S., Canada, and Puerto Rico from June 2005 through March 2009.
The patients were assigned to one of three groups: paroxetine, venlafaxine, or placebo.
The patients took a maximum of 40 milligrams of paroxetine or 225 mg of venlafaxine daily.
The researchers evaluated their depression at the start and throughout the 12-week study. They looked to see if the treatment affected their movement ability.
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What To Know About Taking These Drugs
The medications work by blocking acetylcholine, a chemical that helps relax and contract your muscles.
When this chemical is blocked, peoples memory and attention can become impaired which is the reason so many people complain of acute confusion and memory loss while taking these medications.
Its thought that over time anticholinergics can inhibit these cognitive functions and eventually make certain people more vulnerable to the type of degeneration that occurs in dementia.
Long-term blockage of the transmitter may lead to an acceleration of memory loss or even potentially degeneration of these types of cells in the brain, Dr. David Merrill, a neurologist and geriatric psychiatrist at Providence Saint Johns Health Center in Santa Monica, told Healthline.
Still, more research is needed to better understand exactly why anticholinergic drugs may increase peoples risk of dementia.
While there may be other factors at play, the researchers suspect that anticholinergics may cause about 10 percent of all new dementia cases.
If youre on any anticholinergics drugs, you may want to check in with your doctors about these risks, health experts warn.
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Should You Stop Taking Your Medications
According to the researchers, people should definitely weigh their drugs benefits alongside the risks to determine if alternative treatments are available.
Ask your doctor whether the drugs youre taking have strong anticholinergic properties. If they do, it may be worth looking into other medication options.
Fortunately, for most of these drugs there are alternative or newer drugs in the same category of the original drug that have little or no anticholinergic effects, Longo said.
That said, you shouldnt stop taking your medications abruptly without first talking to your doctor about your options, he added.
Earlier this year, the World Health Organization released new guidelines on how to lower your chances of getting dementia.
The key, it seems, is to follow a healthy lifestyle.
Eat a well-balanced diet by loading up on fruit, veggies, fish, and whole grains.
Regular exercise can also keep your brain sharp and cut your chances of experiencing cognitive decline. Most experts recommend getting about 150 minutes of moderate physical activity a week.
Alcohol and cigarette use has also been linked to dementia, so if you want to keep your brain healthy, youll want to cut back on those.
That said, moderate consumption of alcohol think a couple glasses of wine a week may actually reduce your risk of dementia.
Use it or lose it is a true refrain for muscle strength and bone density, Merrill said. We now know the same is also for brain health.
Your Parkinsons Drug Treatment
Dopamine is a chemical messenger made in the brain. The symptoms of Parkinsons appear when dopamine levels become too low. This is because many of the cells in your brain that produce dopamine have died or are dying. Taking dopamine as a drug doesnt work because it cannot cross the blood brain barrier. To get around this, doctors use other medication that can act in a similar way.
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Treatment Of Late Stage Complications Of Parkinsons Disease
Postural hypotension
Levodopa and dopamine agonists worsen postural hypotension and it may be necessary to lower the dose of levodopa or withdraw the agonist. Treatment is difficult, but patients should be advised to sleep with the head of the bed raised by one or two bricks and to add salt to their diet. Fludrocortisone can then be added at a dose of 0.1 mg in the morning, increasing if necessary up to 0.5 mg in the morning. If these measures are ineffective, the alpha agonist midodrine 10-20 mg four hourly can be useful but it is experimental and only available via the Special Access Scheme. Patients treated for postural hypotension need to have electrolytes, renal function and supine blood pressures closely monitored.
Parkinsonian psychosis, depression and dementia
Psychotic symptoms such as visual hallucinations and persecutory delusions occur most commonly in the setting of dementia, which may be mild and therefore easily missed. Most drugs for Parkinsons disease make these symptoms worse. Depression is also common and requires treatment in its own right.
A Critical Reappraisal Of The Worst Drugs In Parkinsons Disease
What are the worst drugs for Parkinsons disease patients? Couldnt a simple list be assembled and disseminated to the Parkinson community? Recently Ed Steinmetz, an experienced neurologist in Ft. Meyers, FL pointed out to me, a list approach published in the Public Citizen Newsletter . The approach was to list every drug associated with a single confirmed or unconfirmed symptom of Parkinsons disease or parkinsonism. Parkinsons disease is defined as a neurodegenerative syndrome , whereas parkinsonism encompasses a wider net of drug induced and other potential causes. In parkinsonism symptoms are similar to Parkinsons disease, but patients do not have Parkinsons disease. Patients and family members confronted with a simple drug list approach may falsely conclude that most medicines are bad for Parkinsons disease, and that any medicine may cause parkinsonism. This concept is in general, incorrect. Although the approach is well-meaning, it is in need of a major revision, as Parkinsons disease and parkinsonism are too complex to summarize by simple lists. In this months column I will try to summarize the key information that patients and family members need to know about the worst pills, for Parkinsons disease and parkinsonism.
A Florida Parkinsons Treatment Blog by Michael S. Okun, M.D.
UF Center for Movement Disorders & Neurorestoration, Gainesville FL
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Medications To Avoid Or Use With Caution
Sign up for our email list and receive our publication on medications with potential complications you should be aware of.
Before making any decisions about treatment of Parkinsons disease, you will want to learn about the different types of medications available for Parkinsons disease and discuss the pros and cons of each with your physician. It may help to know that there is no right answer, and if you try something that doesnt work for you, you can always adjust your plan.
To learn more about adjusting medication plans, view our webinar on What to Do When Your Medications Stop Working.
Impulsive And Compulsive Behaviours
People who experience impulsive and compulsive behaviours cant resist the temptation to carry out an activity often one that gives immediate reward or pleasure.
Behaviours may involve gambling, becoming a shopaholic, binge eating or focusing on sexual feelings and thoughts. This can have a huge impact on peoples lives including family and friends.
Not everyone who takes Parkinsons medication will experience impulsive and compulsive behaviours, so these side effects should not put you off taking your medication to control your symptoms.
If you have a history of behaving impulsively you should mention this to your GP, specialist or Parkinsons nurse.
Asking your specialist to make changes to your medication regime or adjusting the doses that you take is the easiest way to control impulsive and compulsive behaviours. So, if you or the person you care for is experiencing this side effect, tell your healthcare professional as soon as possible before it creates large problems.
If you are not able to get through to your healthcare professional straight away, you can call our Parkinsons UK helpline on 0808 800 0303.
We have advice that can help you manage impulsive and compulsive behaviours as well as information on what behaviour to look out for.
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What Are Anticholinergic Antiparkinson Agents
Anticholinergic antiparkinson agents or acetylcholine antagonists block the muscarinic acetylcholine receptors and cholinergic nerve activity. Activation of muscarinic receptors has an excitatory effect, opposite to that of dopaminergic activation, so suppression of the effects of acetylcholine compensates for a lack of dopamine in Parkinson’s disease. Acetylcholine and dopamine have to be carefully balanced for proper body movement. Anticholinergic agents create a better balance between acetylcholine and dopamine. Anticholinergic agents are used to treat patients with Parkinson’s disease who have tremor.
Levodopa: The Most Effective Drug For Treating Parkinsons
Levodopa, also known as L-DOPA, has long been, and continues to be, the most effective drug in treating Parkinsons disease symptoms. Most people with Parkinsons disease will take this drug at some point. There are side effects that can occur with Levodopa including nausea, fatigue and orthostatic hypotension. Often these side effects can be successfully treated so that Levodopa can be tolerated better. In addition, as the disease progresses and the brain has less ability to produce and process dopamine, dyskinesias, or involuntary movements can develop from Levodopa.
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What Are Anticholinergics
Anticholinergics are a class of drugs used to treat a wide range of medical conditions, from asthma to the side effects of certain psychiatric medications. They are also used to treat some symptoms of Parkinsons disease.
They can help to decrease the involuntary movement of muscles in your body that are part of the disease. For instance, with Parkinsons disease, anticholinergics are used to control tremors that are commonly characteristic of the condition.
Generic Vs Branded Drugs
Currently, there are multiple pharmaceutical companies that manufacture a generic formulation of carbidopa-levodopa, dopamine agonists, monoamine oxidase inhibitors, and anticholinergics. The U.S. Food and Drug Administration requires that generic drugs show a similar risk and benefit to the branded drug prior to market approval, but in rare cases this standard is not high enough.
A review supported by the Parkinsons Foundation reports evidence that if you are in more advanced stages of the disease, switching from branded drugs to generic, or from one generic to another, may have somewhat variable effects. The authors, including Parkinsons Foundation National Medical Advisor Michael S. Okun, MD, believe that the standards for approving generic drugs for PD may not be strict enough to demonstrate that the generic alternatives are equally effective.
Work with your doctor to develop a tailored treatment plan. Using generic drugs will likely provide a cost savings. Infrequently, a person living with PD may require brand medication.
If you make the switch, follow these tips:
- Report to your physician on the effectiveness of the drugs.
- Carefully keep a diary of any side effects.
- Record dose adjustments made by your physicians .
- Try to stay with a single drug manufacturer for your generic medications. You may need to ask your pharmacist to special order for you.
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New Medications For Off Time
A number of new medications approved recently are designed to reduce OFF time. These medications fall into two major categories:
- Medications that lengthen the effect of a carbidopa/levodopa dose
- Medications that are used as needed if medication effects wear off
Well give specific examples below. In general, new medications that extend the length of a carbidopa/levodopa dose are used if OFF time is somewhat predictable and occurs prior to next dose. New medications that are used as needed are most beneficial when OFF time is not predictable.
New medications that lengthen the effect of a dose of carbidopa/levodopa
- Istradefylline is an adenosine A2A receptor antagonist which was approved in the US in 2019 as an add-on therapy to levodopa for treatment of OFF time in PD. Unlike many of the other medications, it has a novel mechanism of action and is the first medication in its class to be approved for PD. It acts on the adenosine receptor, which modulates the dopaminergic system, but is not directly dopaminergic. The drug was developed in Japan and underwent clinical trials both in Japan and in the US.
- Opicapone is a catechol-O-methyltransferase inhibitor that is taken once a day. It was approved in the US in 2020 as an add-on therapy to levodopa for motor fluctuations.
New formulations of levodopa designed to be used as needed if medication effects wear off
Other medications used as needed if medication effects wear off
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Cholinomimetics or cholinergic drugs are those drugs that cause effects similar to those resulting from introduction of acetylcholine, or simulation of ganglions of the parasympathetic nervous system. These drugs imitate action of endogenously released acetylcholine. Acetylcholine is the primary neurotransmitter in the parasympathetic division.
259. Spohn A.E., Strauss H.E. Relation of neuroleptic and anticholinergic medication to cognitive Serum levels of anticholinergicdrugs and impaired recent memory in chronic schizophrenic.
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Pain Relievers And Other Options
If youre in pain, your doctor may suggest you take over-the-counter pain relief medications such as Motrin , Aleve or aspirin. These medications may work to relieve minor aches and pains that you experience from your Parkinsons disease due to immobility, stiffness, and rigidity.
However, your doctor may want to try some other remedies first. These options include:
- Adjusting your Parkinsons medications. Since pain can be caused by the muscle-related symptoms of Parkinsons disease, its possible that it can be managed by adjusting the medications prescribed to manage those symptoms. Your doctor is the best judge of whether this is possible, and how to accomplish it.
- Exercise. Again, most persistent pains in Parkinsons are due to the motor problems associated with the condition. An exercise program can help you alleviate those motor problems, which should, in turn, cause the accompanying aches and pains to diminish. Talk to your doctor about starting such an exercise program.
Other options to treat pain in Parkinsons disease include massage, physical therapy, and stretching.
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Medication Names And Forms
Most medications have two names. The generic name describes the active ingredient in the drug. Every drug that has the same active ingredient will have the same generic name, no matter who manufactures it. The different drug companies who produce the medication market it using a brand or trade name and these may vary from country to country.
For example, the levodopa group of drugs can exist in a number of forms. Each of these contains the chemical levodopa in combination with a second chemical called carbidopa. Together, these are referred to as co-careldopa.
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Not all medications are available in each of the European countries, and they may have different brand names. You can obtain further details from your national regulatory authority. Contact details can be obtained from the European Medicines Agency website.