Treatments for PARKINSON'S DISEASE

Carbidopa-levodopa. Levodopa, the most effective Parkinson's disease medication, is a natural chemical that passes into your brain and is converted to dopamine. Levodopa is combined with carbidopa (Lodosyn), which protects levodopa from early conversion to dopamine outside your brain. This prevents or lessens side effects such as nausea. Side effects may include nausea or lightheadedness (orthostatic hypotension). However, many find the benefit from levodopa has a tendency to wax and wane ("wearing off", with "ON" and "OFF" episodes). To better manage this -- and it's quite common -- a third medication -- entacapone, or opicapone -- can be taken (see Salat & Tolosa, 2013). After years, as your disease progresses, you may experience involuntary movements (dyskinesia) after taking higher doses of levodopa. Your doctor may lessen your dose or adjust the times of your doses to control these effects.
Carbidopa-levodopa infusion. Duopa is a brand-name medication made up of carbidopa and levodopa. However, it's administered through a feeding tube that delivers the medication in a gel form directly to the small intestine. Duopa is for patients with more-advanced Parkinson's who still respond to carbidopaD levodopa, but who have a lot of fluctuations in their response. Because Duopa is continually infused, blood levels of the two drugs remain constant. Placement of the tube requires a small surgical procedure. Risks associated with having the tube include the tube falling out or infections at the infusion site. Mundt-Petersen & Odin (2017)
Dopamine agonists. Unlike levodopa, dopamine agonists don't change into dopamine. Instead, they mimic dopamine effects in your brain. They aren't as effective as levodopa in treating your symptoms. However, they last longer and may be used with levodopa to smooth the sometimes off-and-on effect of levodopa. Dopamine agonists include pramipexole (Mirapex), ropinirole (Requip) and rotigotine (Neupro, given as a patch). Apomorphine (Apokyn), is a short-acting injectable dopamine agonist used for quick relief. Some of the side effects of dopamine agonists are similar to the side effects of carbidopa-levodopa. But they can also include hallucinations, sleepiness and compulsive behaviors such as hypersexuality, gambling and eating (see, for example, Corvol et al 2018. If you're taking these medications and you behave in a way that's out of character for you, talk to your doctor.
MAO B inhibitors. These medications include selegiline (Eldepryl, Zelapar), rasagiline (Azilect) and safinamide (Xadago). They help prevent the breakdown of brain dopamine by inhibiting the brain enzyme monoamine oxidase B (MAO B). This enzyme metabolizes brain dopamine. Side effects may include nausea or insomnia. When added to carbidopa-levodopa, these medications increase the risk of hallucinations. These medications are not often used in combination with most antidepressants or certain narcotics due to potentially serious but rare reactions. Check with your doctor before taking any additional medications with an MAO B inhibitor. MAO Bs have in the past primarily been used as antidepressants -- dopamine being keen to the brain's "reward processing" -- hence depreession often being a symptom / disorder prior to the diagnosis of PD, sometimes years before.
Catechol O-methyltransferase (COMT) inhibitors. Entacapone (Comtan) is the primary medication from this class. This medication mildly prolongs the effect of levodopa therapy by blocking an enzyme that breaks down dopamine. Side effects, including an increased risk of involuntary movements (dyskinesia), mainly result from an enhanced levodopa effect. Other side effects include diarrhea or other enhanced levodopa side effects. Tolcapone (Tasmar) is another COMT inhibitor that is rarely prescribed due to a risk of serious liver damage and liver failure. However, there is some evidence Opicapone (Ongentys), another COMT inhibitor used to supplement dopamine can be more effective and safer than Entacapone (Ferreira et al, 2018)
Anticholinergics. These medications were used for many years to help control the tremor associated with Parkinson's disease. Several anticholinergic medications are available, including benztropine (Cogentin) or trihexyphenidyl. However, their modest benefits are often offset by side effects such as impaired memory, confusion, hallucinations, constipation, dry mouth and impaired urination.
Amantadine. Doctors may prescribe amantadine alone to provide short-term relief of symptoms of mild, early-stage Parkinson's disease. It may also be given with carbidopa- levodopa therapy during the later stages of Parkinson's disease to control involuntary movements (dyskinesia) induced by carbidopa-levodopa. Side effects may include a purple mottling of the skin, ankle swelling or hallucinations.
Tricyclic Antidepressants There is some research (Collier et al, 2017 and for treatment guidelines see here) now showing that such tricyclic antidepressants as nortriptyline might slow down the progression of Parkinson's by reducing the amount of misfolded alpha-synuclein and inhibiting the formation of protein aggregates — two well-known hallmarks of Parkinson’s. In the presence of nortriptyline, alpha-synuclein proteins moved and changed shape much faster, which prevented them from clustering. “What we’ve essentially shown is that an already FDA-approved drug that’s been studied over 50 years and is relatively well tolerated could be a much simpler approach to treating the disease itself, not just the symptoms,” said Collier, adding that it remains to be determined whether targeting alpha-synuclein is the optimal approach or if this complex disorder is best served by combination therapies. In addition, it's tempting to think of whether or not the anticholinergic effects of such medications might be useful to counter other symptoms of PD, such as tremor, polyuria, sialorrhea (drooling), diarrhea etc.

Deep brain stimulation. In deep brain stimulation (DBS), surgeons implant electrodes into a specific part of your brain. The electrodes are connected to a generator implanted in your chest near your collarbone that sends electrical pulses to your brain and may reduce your Parkinson's disease symptoms. Your doctor may adjust your settings as necessary to treat your condition. Surgery involves risks, including infections, stroke or brain hemorrhage. Some people experience problems with the DBS system or have complications due to stimulation, and your doctor may need to adjust or replace some parts of the system. Deep brain stimulation is most often offered to people with advanced Parkinson's disease who have unstable medication (levodopa) responses. DBS can stabilize medication fluctuations, reduce or halt involuntary movements (dyskinesia), reduce tremor, reduce rigidity, and improve slowing of movement. DBS is effective in controlling erratic and fluctuating responses to levodopa or for controlling dyskinesia that doesn't improve with medication adjustments. However, DBS isn't helpful for problems that don't respond to levodopa therapy apart from tremor. A tremor may be controlled by DBS even if the tremor isn't very responsive to levodopa. Although DBS may provide sustained benefit for Parkinson's symptoms, it doesn't keep Parkinson's disease from progressing.
NON-INVASIVE NEUROMODULATION METHODS (for overview see Biagioni, et al, 2018) Transcranial noninvasive brain stimulation includes both repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS) (Rektorová & Anderková, 2017). rTMS uses a rapidly changing magnetic field to induce currents and action potentials in underlying brain tissue, whereas tDCS involves the application of weak electrical currents to modulate neuronal membrane potential. On the whole, the results of studies are rather preliminary but promising as they show some positive effects of rTMS and tDCS particularly on depressive symptoms and cognitive dysfunctions in PD. More carefully controlled trials with standardized methodology, adequately sized and well-characterized samples, and the inclusion of multimodal approaches are warranted in the future.

Physical Exercise -- See the material from the Brian Grant Foundation here, and my collection of journal articles and other materials here. This topic is so crucially important, yet so big, it really demands at least a special page of its own -- yet to come!
Diet and Nutrition -- See the comments by Bas Bloem in video 4 of the Introduction; as well as here as well as discussion of its importance to maintaining cognitive function in the advancing years here -- a topic still in need of much better quality research, often missing in treatments provided in southern New Zealand, but likely to become increasingly recognised as being crucially important,
Mind-Body Approaches -- Tai Chi An ancient form of Chinese exercise, tai chi employs slow, flowing motions that may improve flexibility, balance and muscle strength. Tai chi may also prevent falls. Several forms of tai chi are tailored for people of any age or physical condition. A study showed tai chi may improve the balance of people with mild to moderate Parkinson's disease more than stretching and resistance training. Yoga In yoga, gentle stretching movements and poses may increase your flexibility and balance. You may modify most poses to fit your physical abilities
Mindfulness-Meditation -- The merits of these are still being actively researched, yet we are still awaiting better quality, prospectively conducted research
Comprehensive or "Third Wave" approaches -- Still not being actively studied in relation to PD, but approaches such as those developed by Ken Pakenham of the University of Queensland -- see program overview here -- are thought by Prof Pakenham to be transferable to us.
Music, Dance, the Ronnie Gardiner Method -- Again, still an area awaiting better quality research, but briefly discussed -- search topic of interest here

Parkinson's Disease

TREATMENT AND LIFESTYLE OPTIONS -- An Introduction

An Introduction to PD here

More in-depth information here

Information Sources

Practice Base Foundation

Discussion of, and links to relevant research on, issues of the role of self-management, self-efficacy, quality of life, and palliatice care as applied to longterm conditions such as Parkinson's Disease

DRUG TREATMENTS

NEUROMODULATION INTERVENTIONS

including Deep Brain Stimulation

LIFESTYLE ADJUSTMENT AND COMPLEMENTARY APPROACHES

CONTACT FORM

Your comments on the site,
including any reports of difficulties you have using it, are welcome

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Parkinson's Disease

TREATMENT AND LIFESTYLE OPTIONS -- An IntroductionAn Introduction to PD hereMore in-depth information here

Information Sources

Practice Base Foundation

Discussion of, and links to relevant research on, issues of the role of self-management, self-efficacy, quality of life, and palliatice care as applied to longterm conditions such as Parkinson's Disease

DRUG TREATMENTS

NEUROMODULATION INTERVENTIONS including Deep Brain Stimulation

LIFESTYLE ADJUSTMENT AND COMPLEMENTARY APPROACHES

CONTACT FORM

Your comments on the site, including any reports of difficulties you have using it, are welcome

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Home

Website Developer

Legal

TREATMENT AND LIFESTYLE OPTIONS -- An Introduction

An Introduction to PD here

More in-depth information here

NEUROMODULATION INTERVENTIONS

including Deep Brain Stimulation

Your comments on the site,
including any reports of difficulties you have using it, are welcome