When To Start Parkinson’s Medication

Medication Administration In The Management Of Parkinson Disease

A Position Paper Prepared by the Michigan Parkinson FoundationProfessional Advisory Board: May 2013

Persons with Parkinson disease consistently do not get their medications appropriately while hospitalized or in long term care facilities. Long-standing difficulties experienced center around the timing of medication administration and receiving drugs which interact with PD medications. The Professional Advisory Board of the Michigan Parkinson Foundation has studied this issue and joins several national and international Parkinsons disease organizations in recommending the development of programs and procedures to address care in these settings.

Thus far, the focus of programs to address these issues has targeted education of people with PD and their families to advocate for themselves when entering hospitals or long-term care facilities. This form of advocacy may assist in averting problems but does not address the root causes, which can add unnecessary stress to vulnerable individuals and families by forcing them to advocate for their own care. The Professional Advisory Board recommends that institutional level care should consider the following:

I must be given my medication promptly at the times specifiedThe timing of my medication is very important to help minimize my symptoms andoff times.For example: Sinemet often should be taken 30 minutes prior to or one hour after meals, because a meal sometimes delays the levodopa from reaching the brain.

Recommendations

Controlled Release Madopar And Sinemet

Controlled release preparations have the letters CR or HBS after the drug name.

These let the levodopa enter your body slowly instead of all at once. They can increase the time between doses.

They may be used when the dose of standard levodopa starts to wear off and the person taking it no longer feels the treatment is effective.

Controlled release options can sometimes reduce involuntary movements .

Looking Out For Side Effects If You’re A Carer

If youre a carer of someone with Parkinsons, medication side effects can be difficult and tiring to cope with.

It may be that the person having side effects such as hallucinations and delusions or impulsive and compulsive behaviour does not realise they are experiencing them.

Its important to seek help from your specialist as soon as you can.

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What Are Surgery Options For Parkinsons Disease

Depending upon your needs, medical history, health, and symptoms, one of the following procedures may be considered for Parkinsons disease:

There are many other procedures being researched. One of the most promising involves the transplantation of fetal dopamine neurons into the brains of people with Parkinsons disease. The hope is that these cells will be able to re-grow the damaged dopamine-producing nerve cells.

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Understanding The Levodopa Side Effect

If you have Parkinsons disease, there is a good chance that youve been, or will be taking medication containing levodopa. Levodopa is administered in combination with the drug carbidopa . This drug combination is considered standard treatment for Parkinsons disease symptoms such as tremor, muscle stiffness, and slowness of movement. A side effect of long-term use of levodopa is dyskinesia. Below, you will learn about dyskinesia, what causes it, how it can be managed, and some basic coping strategies.

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Symptomatic And Neuroprotective Therapy

Pharmacologic treatment of Parkinson disease can be divided into symptomatic and neuroprotective therapy. At this time, there is no proven neuroprotective or disease-modifying therapy.

Levodopa, coupled with carbidopa, a peripheral decarboxylase inhibitor , remains the gold standard of symptomatic treatment for Parkinson disease. Carbidopa inhibits the decarboxylation of levodopa to dopamine in the systemic circulation, allowing for greater levodopa distribution into the central nervous system. Levodopa provides the greatest antiparkinsonian benefit for motor signs and symptoms, with the fewest adverse effects in the short term however, its long-term use is associated with the development of motor fluctuations and dyskinesias. Once fluctuations and dyskinesias become problematic, they are difficult to resolve.

Monoamine oxidase -B inhibitors can be considered for initial treatment of early disease. These drugs provide mild symptomatic benefit, have excellent adverse effect profiles, and, according to a Cochrane review, have improved long-term outcomes in quality-of-life indicators by 20-25%.

Neuroprotective therapy aims to slow, block, or reverse disease progression such therapies are defined as those that slow underlying loss of dopamine neurons. Although no therapy has been proven to be neuroprotective, there remains interest in the long-term effects of MAO-B inhibitors. Other agents currently under investigation include creatine and isradipine.

I Am Going Into Hospital For A Planned Admission And I Want To Make Sure I Get My Medication On Time How Can I Do This

Many hospitals will allow you to take your medication yourself during your stay. You can check this before you are admitted. Some hospitals dont allow patients to take their own medication and it has to be given to you by the ward nurse. If this is the case in the hospital you are going to make sure they know that you need your medication at times which are specific to you and your condition. Your Parkinsons nurse could help you arrange this.

When you go into hospital for a planned operation, you will often have a meeting to discuss your needs, known as a pre-operation assessment. This is a good time to tell medical staff that you need your medication at specific times and that you cant miss a dose.

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Names Of Parkinsons Drugs

Drugs for Parkinsons can be divided into three categories.

On our website, we have listed drugs in the following order to help you see each category clearly.

• The class or type of drug, for example levodopa.
• The generic name, such as co-beneldopa, which will include the active ingredients of the drug. For example, co-beneldopa is a combination of levodopa and benserazide.
• The brand name. For example, Madopar is the name that the pharmaceutical company, Roche, uses to sell co-beneldopa.

Your specialist will decide whether to prescribe you branded or generic versions of your medication. It usually depends on which area of the country you are in or what is most common to prescribe in that area. Once there are no longer any legal rights to the brand name any company can make generic versions of a drug.

The active ingredient of a generic drug is always the same as the branded version and lots of people wont have any problems using the generic medication.

In the UK, a generic or branded medicine needs a licence and there is a strict process for this. This means that the quality of a generic or branded version of the same medicine will be the same, and they will also act in the same way.

If you find that you respond a bit differently to generic medication, discuss this with your specialist or Parkinsons nurse.

The brand name will usually be the most visible name on your packet of medication. The generic name is usually written in small print.

Could Environmental Factors Also Be Contributing

Research is in its infancy, but Parkinson’s expert Ray Dorsey has concluded the disease is increasing faster than aging, so there are other drivers, likely environmental.

Some research has implicated the pesticide paraquat, though not all studies confirm that connection. Lawsuits are ongoing against the manufacturers of paraquat by individuals with Parkinson’s people, Dorsey said, who have no family history or identifiable genetic cause of the disease, but who were exposed to paraquat before developing Parkinson’s.

Air pollution also might be raising the Parkinson’s disease risk, Dorsey said, as might the degreasing agent Trichloroethylene or TCE.

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Side Effects And Problems Of Anticholinergics

Another reason these drugs are not a first choice for treating Parkinsons are their side effects. Some people may experience confusion, a dry mouth, constipation and blurred vision when taking anticholinergics.

Anticholinergics may interfere with levodopa absorption in the small bowel, which reduces the effectiveness of Madopar or Sinemet, forms of the drug levodopa.

Anticholinergics are not usually prescribed to older people with Parkinsons because there is an increased risk of memory loss and, in men, problems urinating.

Im Worried If I Start Taking Medication I Will Develop Side Effects What Should I Do

Its natural to worry about side effects. Its good to be informed, but dont dwell on them. Your specialist or Parkinsons nurse will always talk to you about the main ones, such as dyskinesia and impulsive and compulsive behaviours at your appointments.

If you start medication and do start developing side effects, you should talk to your specialist or Parkinsons nurse. They can come up with a plan for you to come off the medication slowly and consider a different option.

• If you do choose to take medication for your condition, it is important that you dont stop taking it without first discussing it with your specialist or Parkinsons nurse.Find out more about drug treatments for Parkinson’s.

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Making The Most Of On Time

Although there are many approaches to managing off time, it often becomes harder to control motor fluctuations over time. Once you get a sense of when your off times are likely to occur possibly with the help of a motor symptom journal you can better plan your day. Take advantage of on times when symptoms are well-controlled to be active, and try to make sure off times happen at times when it matters less.

Each persons daily schedule will look different based on when off time occurs which may be as a dose of Parkinsons medication wears off, in the morning before the first dose, or while waiting for a dose to take effect. It may also depend on other medications you take, whether for Parkinsons or another medical condition.

As you make your schedule, take into account:

• Timing meals for best medication effectiveness
• Getting sunlight and physical activity early in the day if possible
• Minimizing drinking before bedtime to avoid needing to get up to urinate
• Taking any sedating medication later in the day, closer to bedtime

For some MyParkinsonsTeam members, the morning is peak on time. Best time for me is early in the morning, wrote one member. I clean house, do yoga, then have a big breakfast at about 6:30. Another shared, Walked three miles this morning. If I dont walk in the morning, by the afternoon Im spent! No energy!

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What Other Information Should I Know

Keep all appointments with your doctor and the laboratory. Your doctor will order certain lab tests to check your response to levodopa and carbidopa.

Before having any laboratory test, tell your doctor and the laboratory personnel that you are taking levodopa and carbidopa.

Levodopa and carbidopa can lose its effect completely over time or only at certain times during the day. Call your doctor if your Parkinson’s disease symptoms worsen or vary in severity.

As your condition improves and it is easier for you to move, be careful not to overdo physical activities. Increase your activity gradually to avoid falls and injuries.

Levodopa and carbidopa can cause false results in urine tests for sugar and ketones .

Do not let anyone else take your medication. Ask your pharmacist any questions you have about refilling your prescription

It is important for you to keep a written list of all of the prescription and nonprescription medicines you are taking, as well as any products such as vitamins, minerals, or other dietary supplements. You should bring this list with you each time you visit a doctor or if you are admitted to a hospital. It is also important information to carry with you in case of emergencies.

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How Do I Take Care Of Myself

If you have Parkinsons disease, the best thing you can do is follow the guidance of your healthcare provider on how to take care of yourself.

• Take your medication as prescribed. Taking your medications can make a huge difference in the symptoms of Parkinson’s disease. You should take your medications as prescribed and talk to your provider if you notice side effects or start to feel like your medications aren’t as effective.
• See your provider as recommended. Your healthcare provider will set up a schedule for you to see them. These visits are especially important to help with managing your conditions and finding the right medications and dosages.
• Dont ignore or avoid symptoms. Parkinsons disease can cause a wide range of symptoms, many of which are treatable by treating the condition or the symptoms themselves. Treatment can make a major difference in keeping symptoms from having worse effects.

Why Might Someone Choose To Delay Taking Medication

If you have mild symptoms that are not impacting your day-to-day life, you may decide not to start treatment immediately.

Your specialist will consider the impact your symptoms are having on you age is less of a factor. For example, if your symptoms are impacting your daily life, your specialist may recommend you start medication. If you have very mild symptoms, you and your specialist may agree to wait until symptoms become more difficult.

Some people may not want to start taking medication because of the potential side effects. If you take levodopa for a long time, you might start to develop side effects, such as dyskinesia . But not everyone will experience severe problems and medication can usually be adjusted to minimise them.

Sometimes starting medication immediately can be helpful. If your specialist isnt sure whether you have Parkinsons, they may suggest medication to see how your symptoms respond. Drug treatments can then help determine a diagnosis.

Parkinsons symptoms can improve with medication. This is why its important that delaying treatment should be a joint decision made between you and your specialist.

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Side Effects And Problems With Dopamine Agonists

Common side effects of dopamine agonists include:

• Nausea and vomiting
• Hallucinations or delusions and confusion
• Existing dyskinesias becoming more troublesome initially

If you are taking Cabergoline , Pergolide or Bromocriptine your neurologist or GP will have to arrange a chest CT scan or ultrasound of your heart yearly as over time these medications may effect heart or lung tissue.

This precaution does not apply to the other dopamine agonists available in Australia.

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What Are The Different Types Of Pain Experienced By People With Parkinsons

Five main types of pain are common for people with Parkinsons. Multiple types may be present simultaneously or occur at different points throughout a persons path with Parkinsons. Recognizing which kind of pain is present can help you optimize treatment, as can paying attention to what activities or times of day make your pain better or worse.

Musculoskeletal pain

Musculoskeletal pain that affects muscles, bones, tendons, ligaments, and/or nerves. The pain can be localized or generalized and can fade or intensify at different times. Existing musculoskeletal pain can be exacerbated by Parkinsons.

Neuropathic pain

Rather than being caused by a physical injury, this type of pain is caused by damage to the somatosensory nervous system or a disease affecting the somatosensory nervous system, which responds to external stimuli like touch, temperature, and vibration. It tends to be fairly consistent throughout the day and is present no matter what activity youre doing. Unlike the aching you may feel when youre doing a strenuous physical activity, neuropathic pain feels more like a tingly, crawly, uncomfortable sensation.

Dystonic pain

Dystonia, the movement disorder in which involuntary muscle contractions cause repetitive or twisting motions, is often very painful. Many people with Parkinsons experience dystonia as a motor symptom, whether its localized , in multiple nearby body parts , or all over .

Akathisia

Central pain

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When To Start Levodopa In Parkinson’s Disease

Dopamine is a neurotransmitter secreted from the substantia nigra, a small region in the brainstem that withers away in Parkinson’s disease. As natural dopamine levels in the brain begin to fall, signs of Parkinson’s disease appear. If dopamine is replaced, many of the symptoms improve.

One would think, then, that dopamine should be given as soon as possible. There are other options, though. In addition to given dopamine directly , Parkinson’s disease patients may benefit from a class of drugs called dopamine agonists. These are drugs that aren’t dopamine but have similar effects on the nervous system. Some physicians have argued that dopamine agonists should be used earlier in the disease’s course and that only elderly patients with at least moderate disability should receive levodopa.

Alternative Treatments For Parkinsons Disease

Alternative therapy may also be used to treat Parkinsons disease. The most touted in recent years has been the effect of Vitamin E on reversing the progression of the disease although, this effect is still being debated by the scientific community.

Relaxation and guided imagery have also been suggested to help with stress, depression, and anxiety. Medical studies have shown that relaxation and guided imagery may help slow the progression of symptoms as well as quicken healing time after surgeries or injuries.

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How Can I Remember To Take My Parkinsons Medication On Time

There are lots of things you can do to help you get your medication on time.

For example, you could:

• set an alarm on your phone or smart watch

• get a family member to call you at the right time or arrange care visits around when you need to take your medication

• use a pill box with sections for each day and time. You pharmacist can advise on the different ones available and we also sell them on the Parkinsons UK shop

Talk to your Parkinsons nurse if you are struggling to remember to take your medication. They can work with you to reschedule your treatment regime so that it fits around you.