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Extended Release Carbidopa Levodopa In Parkinson Disease

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Immediate, Controlled, & Extended Release Carbidopa/Levodopa – Lunch with Docs® – July 9, 2021

In 2002, the AAN released guidelines about treatment of early PD. Since that time, many new therapeutic options have become available, leading the AAN to release 6 updated recommendations. The neurology group reviewed peer-reviewed studies up until June 2020 that focused on patients with early PD and they also assessed the medications prescribed using the Unified Parkinsons Disease Rating Scale part III, which measures motor symptoms.

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When prescribing patients with early PD medication for their motor symptoms, physicians must weigh the benefits and risks for each patient individually. Clinical trials have found that levodopa better improved mobility than MAO-B inhibitors or DAs. Compared with MAO-B inhibitors, levodopa was associated with decreased risk for adverse event-related discontinuation and most individuals who used MAO-B inhibitors required additional therapy within 2-3 years. Compared with DAs, levodopa was more likely to cause nonsevere dyskinesia and DAs were more likely to cause hallucinations and impulse control disorders.

Like levodopa, DAs come in multiple formulations such as short-acting or long-acting and they are also available in various delivery methods, including oral and as transdermal injection. There was little evidence to support the use of a specific

Disclosure: Multiple authors declared affiliations with industry. Please refer to the original article for a full list of disclosures.


Patients With No Fluctuations

In early PD, all levodopa formulations may be expected to be effective, and a long-term advantage of any one of them over the others has not been empirically studied. Candidates for conversion to ER CD/LD might include patients prone to miss IR CD/LD doses and patients intolerant of dopamine agonists. The recommended initial dosage is 95 mg TID. If the response is suboptimal, the dosing can be uptitrated to 145 mg TID . Further increases may be considered , by increments of 50 mg per ER CD/LD dose, on a weekly basis or slower.

A Glimpse On Levodopa History

Parkinsons disease is a neurodegenerative disorder characterized by cardinal motor features, such as bradykinesia, rigidity, postural instability and resting tremor, and non-motor features, ranging from depression to hyposmia . PD is the most common chronic neurodegenerative disease affecting motor behaviour, and its prevalence increases with age, from 2% in over 65 years old to 5% in over 85 years old . PD is characterized by the progressive loss of dopaminergic pigmented neurons of the substantia nigra pars compacta, a small structure lying deep in the core of the human midbrain . Among these neuronal cells, DA is synthesized from the L-3,4-dihydroxyphenylalanine deriving from the hydroxylation of tyrosine . This pathway, the only one available in the SN for DA production , leads to DA synthesis in its first stage, eventually producing other catecholamines, such as noradrenaline and adrenaline, by the action of aromatic L-amino acid decarboxylase . From the first depiction, dating back to Parkinsons original paralisis agitans , it took more than a century to unveil the distribution of cathecolamines among the central nervous system , and almost 40 years to shed light on the dopamine deficiency peculiar of PD . From such pioneering reports the levodopa era starts.

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What Should I Know About Storage And Disposal Of This Medication

Keep this medication in the container it came in, tightly closed, and out of reach of children. Store it at room temperature and away from excess heat and moisture .

Store cassettes containing levodopa and carbidopa enteral suspension in the refrigerator in their original carton, protected from light. Do not freeze the suspension.

Unneeded medications should be disposed of in special ways to ensure that pets, children, and other people cannot consume them. However, you should not flush this medication down the toilet. Instead, the best way to dispose of your medication is through a medicine take-back program. Talk to your pharmacist or contact your local garbage/recycling department to learn about take-back programs in your community. See the FDA’s Safe Disposal of Medicines website for more information if you do not have access to a take-back program.

It is important to keep all medication out of sight and reach of children as many containers are not child-resistant and young children can open them easily. To protect young children from poisoning, always lock safety caps and immediately place the medication in a safe location â one that is up and away and out of their sight and reach.

How To Use Carbidopa

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Take this medication by mouth as directed by your doctor, usually 3 times a day.

Swallow the capsules whole. Do not crush or chew the capsules. Doing so can release all of the drug at once, increasing the risk of side effects. If you have trouble swallowing the capsule, you may open up the capsule and sprinkle the entire contents onto a small amount of applesauce. Swallow all of the mixture right away without chewing it. Do not prepare the mixture ahead of time for later use.

This medication may be taken with or without food. However, avoid high-protein diets because they may reduce how much of the medication you can absorb. Also avoid taking this medication with a high-fat, high-calorie meal since this can slow down the time it begins to work by about 2 hours. The manufacturer says you should take your first dose of the day about 1 to 2 hours before eating. Ask your doctor or pharmacist how best to take this medication.

Separate your dose of this medication as many hours as possible from any iron supplements or products containing iron you may take. Iron can reduce the amount of carbidopa/levodopa that is absorbed by your body.

Do not take other forms of carbidopa or levodopa without consulting your doctor first.

Take this medication regularly to get the most benefit from it. To help you remember, take it at the same times each day. The dosage is based on your medical condition and response to treatment.

Tell your doctor if your condition does not improve or if it worsens.

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Carbidopa/levodopa Orally Disintegrating Tablets

This formulation of carbidopa/levodopa dissolves in the mouth. Although it is absorbed in the gut, the fact that it does not have to be broken down in the stomach means that onset of action of the medication is somewhat quicker than regular Sinemet. It is also useful for those who have difficulty swallowing pills.

What Are The Side Effects Of Sinemet

With any medication, there are risks and benefits. Even if the medication is working, you may experience some unwanted side effects.

Contact your doctor immediately if you experience any of the following:

  • Neuroleptic malignant syndrome : very high fevers, confusion, irregular pulse, sweating, muscle stiffness, changes in blood pressure

The following side effects may get better over time as your body gets used to the medication. Let your doctor know immediately if you continue to experience these symptoms or if they worsen over time.

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Er Cd/ld In The Clinic

ER CD/LD is finding its place in clinical practice. If a patient with PD is having motor fluctuations while taking alternative formulations of CD/LD , then ER CD/LD can be offered in an attempt to smooth out the patients day. The ER formulation provides a more simplified drug regimen for the patient with less dosing frequency. The addition of medications such as dopamine agonists and MAO-B inhibitors can be avoided . The use of ER CD/LD also negates the need for the addition of IR to CR CD/LD in patients with delayed onset. A patient may find more overnight relief from motor and nonmotor symptoms with ER CD/LD compared with IR and CR formulations. A given patient may find ER CD/LD more tolerable in terms of LD-related side effects compared with alternative formulations. The institution of ER CD/LD may delay the need for surgical options such as DBS and intestinal LCIG therapy. It is not known whether starting ER CD/LD early in patients with PD will cause less dyskinesia in the future compared with other formulations. Consensus positions among 11 movement disorder specialists on the optimization of ER CD/LD in PD have been reported.

Dose Conversion In Clinical Practice

Carbidopa Levodopa

The conversion procedures utilized in the ER CD/LD clinical trials, may be impractical in clinical practice. Roughly 60% of patients required a dosage higher than those that the trials’ conversion tables had recommended for their initial regimens. In addition, the conversion tables listed only TID regimens . At the end of conversion, the mean dosing frequency was higher than TID . Finally, the tables did not distinguish between patients taking evenly divided levodopa doses and those taking uneven doses , either before or after conversion.

How can the ER CD/LD dosing guidelines based on clinical trials be modified to best suit the individual patient with PD? The advisory meeting considered various clinical scenarios.

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How Does It Work

Dopamine is a neurotransmitter with many jobs. Dopamine is responsible for producing smooth, purposeful movement. PD damages the neurons in the brain that make dopamine. This causes the motor symptoms of PD. This includes symptoms like:1-4

  • Tremor
  • Impaired balance
  • Loss of spontaneous movement

Thesemotor symptomsare related to the loss of dopamine in the brain. By the time motor symptoms of PD appear, about 60 to 80 percent of the neurons in the brain that make dopamine have already been damaged or destroyed.1-4

Dopamine cannot enter our brains. This means that dopamine by itself cannot work as a treatment for PD. However, levodopa can enter the brain. Levodopa is the building block our bodies can use to make dopamine. Levodopa is converted to dopamine in the brain. The influx of dopamine created by levodopa helps treat the motor symptoms of PD.1-4

Adding carbidopa prevents levodopa from being converted into dopamine in the bloodstream. This allows more of the drug to get to the brain. This also means that lower doses of levodopa can be given. The addition of carbidopa also reduces the risk of some side effects like nausea or vomiting.1,2

How Should This Medicine Be Used

The combination of levodopa and carbidopa comes as a regular tablet, an orally disintegrating tablet, an extended-release tablet, and an extended-release capsule to take by mouth. The combination of levodopa and carbidopa also comes as a suspension to be given into your stomach through a PEG-J tube or sometimes through a naso-jejunal tube using a special infusion pump. The regular and orally disintegrating tablets are usually taken three or four times a day. The extended-release tablet is usually taken two to four times a day. The extended-release capsule is usually taken three to five times a day. The suspension is usually given as a morning dose and then as a continuous dose , with extra doses given no more than once every 2 hours as needed to control your symptoms. Take levodopa and carbidopa at around the same times every day. Follow the directions on your prescription label carefully, and ask your doctor or pharmacist to explain any part you do not understand. Take levodopa and carbidopa exactly as directed. Do not take more or less of it or take it more often than prescribed by your doctor.

Swallow the extended-release tablets whole do not chew or crush them.

To take the orally disintegrating tablet, remove the tablet from the bottle using dry hands and immediately place it in your mouth. The tablet will quickly dissolve and can be swallowed with saliva. No water is needed to swallow disintegrating tablets.

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What May Interact With This Medicine

Do not take this medicine with any of the following medications:

  • MAOIs like Marplan, Nardil, and Parnate
  • reserpine

This medicine may also interact with the following medications:

  • alcohol
  • selegiline
  • tolcapone

This list may not describe all possible interactions. Give your health care provider a list of all the medicines, herbs, non-prescription drugs, or dietary supplements you use. Also tell them if you smoke, drink alcohol, or use illegal drugs. Some items may interact with your medicine.

Frequently Asked Questions About Sinemet

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Can I stop taking Sinemet if my Parkinson’s symptoms go away?

Although rare, lowering your dose of Sinemet or stopping the medication can cause high fevers and confusion, especially if you’re taking certain mental health medications. If you want to stop taking Sinemet , let your provider know, so they can instruct you on how to stop the medication safely.

Can I take Sinemet with food?

Sinemet can be taken with food to lower your risk of stomach upset. Avoid eating protein-rich foods, such as meat, milk, cheese, or nuts, with the medication, because they can affect how fast and how much levodopa is absorbed by your body. This can affect how well the medication works.

Can Sinemet cause dark urine?

Yes, Sinemet can turn your urine, sweat, and saliva a dark color . This is harmless, but it can stain your clothing.

How long does it take Sinemet to work?

The medications get released into your body within 30 minutes after you take your dose of the immediate-release or orally disintegrating tablet. On the other hand, the medications are released into your body over 4 to 6 hours after you take the extended-release form. It’s important that you take the medication as prescribed by your provider to get the most relief for your PD symptoms.

What’s the difference between carbidopa/levodopa and carbidopa/levodopa ER?

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What Are The Possible Side Effects

The most common side effects of carbidopa/levodopa therapy include:1

  • Nausea
  • Dry mouth
  • Dizziness

Dyskinesias are a common side effect of long-term levodopa therapy. Dyskinesias can impact quality of life. The severity of dyskinesia due to levodopa varies among people with PD. The risk of dyskinesia is higher inearly-onsetPD. Medicines may be added or adjusted to prevent dyskinesia. Deep brain stimulation may also be an option.3,5

These are not all the possible side effects of carbidopa/levodopa therapy. Talk to your doctor about what to expect when taking carbidopa/levodopa therapy. You should also call your doctor if you have any changes that concern you when taking carbidopa/levodopa therapy.

Hallucinations And Changes In Behavior And Thoughts

  • Risk factors: History of certain mental health conditions

Sinemet and medications that raise your dopamine levels can cause hallucinations and changes in behavior and thinking, such as paranoia, delusions, confusion, aggressive behavior, uneasiness, trouble sleeping, lots of dreaming, and less awareness of your surroundings. Generally, these symptoms can occur shortly after you start taking these medications and they might go away once you stop taking this medication or if your dose is lowered. Because of this risk, you shouldn’t take Sinemet if you have certain mental health conditions. Certain mental health medications, such as haloperidol or perphenazine, can worsen your Parkinson’s disease and might affect how well Sinemet works.

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What Side Effects May I Notice From Receiving This Medicine

Side effects that you should report to your doctor or health care professional as soon as possible:

  • allergic reactions like skin rash, itching or hives, swelling of the face, lips, or tongue
  • anxiety, confusion, or nervousness
  • falling asleep during normal activities like driving
  • fast, irregular heartbeat
  • hallucination, loss of contact with reality
  • mood changes like aggressive behavior, depression
  • stomach pain

What Is Carbidopa/levodopa Therapy

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The combination of levodopa and carbidopa is a treatment used for Parkinsons disease . Levodopa/carbidopa is the most effective treatment available for the motor symptoms of PD. Levodopa was first discovered as a treatment for the symptoms of Parkinsons disease more than 50 years ago.1-4

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Pharmacist Tips For Sinemet

If you were previously taking levodopa, stop taking levodopa at least 12 hours before you start taking the combination medication to lower your risk of side effects. For example, you can take your last dose of levodopa before bedtime and start taking Sinemet in the morning.

Sinemet can make you very sleepy or it can make you fall asleep suddenly with or without warning. Don’t drive or do anything that requires concentration until you know how the medication makes you feel.

You can take Sinemet with food to lower the risk of stomach upset. Avoid taking the medication with food that’s high in protein, such as meat, milk, cheese, or nuts. They can affect how fast and how much medication is absorbed by your body, which can affect how well the medication works.

You might have more difficulty controlling your body’s movements after starting Sinemet . If this becomes bothersome, let your provider know, so they can prescribe a lower dose of medication.

If you’re taking the orally disintegrating tablets, don’t remove the tablets from the bottle until it’s time for your dose. Carefully remove the tablet from the bottle with dry hands, and place it on your tongue. The tablets will dissolve on your tongue, so you donât need to take it with water.

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Pharmacokinetic And Statistical Analyses

Pharmacokinetic parameters for LD and CD were estimated using noncompartmental pharmacokinetic methods . The maximum plasma concentration , and time to peak concentration were observed values. The apparent elimination half-life was calculated as /k, where k is the slope of the log-linear regression of the terminal phase of the concentration-versus-time curve. The area under the plasma concentration-versus-time curve from hour 0 to the last quantifiable concentration at time t was determined by the linear trapezoidal method. The AUC extrapolated to infinity was calculated as AUCinf=AUCt+/k, where Ct is the last measurable concentration. In addition, the duration that LD concentrations were above 50% of Cmax, time for LD concentrations to decrease to less than 10% of Cmax, and the ratio of Cmax/concentration at 6 hours was estimated to characterize the LD profiles of the various formulations. To compare the sustained nature of the LD profile for the various treatments, the time course of Cmax/Ct and the percent deviation from the mean LD concentration were also estimated. In addition, the expected deviation from Cavg at steady state was predicted based on superposition of the single-dose pharmacokinetics. In this prediction, ER CD-LD was dosed every 6 hours and the other CD-LD products were dosed every 3 hours.

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