Parkinson: Motor Symptom Treatments (Detailed Version)
- ALI NAEIMI
- Oct 9, 2024
- 7 min read
There are three main types of dopamine medications used in Parkinson's. These medications all increase the dopamine levels in your brain: dopamine itself, Dopamine agonist medications, and Other medications that keep dopamine in the brain longer (MAO-inhibitors and COMT-inhibitors). Some medicines are used in Parkinson's to handle special situations (e.g., amantadine, anticholinergic medications).
As your Parkinson's changes, our treatment will need to change with it. In later years, your treatment will focus on combining different medications and adjusting your medication dose. You and your Parkinson's care team will work together to define and redefine the appropriate treatment plan for you continuously.
Levodopa:
1. The 'levo' form of dopamine. Your blood carries this form of dopamine from your blood straight into your brain and changes it to natural dopamine. Levodopa is the most effective treatment for Parkinson's disease. When swallowed, levodopa is broken down and absorbed in the stomach. Only a small amount of the medication can reach the brain. For this reason, another substance, carbidopa, is added to levodopa. Carbidopa helps levodopa reach the brain by keeping it from being broken down in your stomach.
The common forms of levodopa are levodopa/carbide (Sinemet), Levodopa/Beneserazide (Prolopa), and Slow-release Levodopa (Sinemet CR), which lasts a little longer and needs to be taken in larger doses for the same effect.
Levodopa will help anyone with Parkinson's disease. So, If there is no improvement with this medication, you may not have Parkinson's disease.
High-protein meals can limit how much of this medication is absorbed in your stomach. Levodopa is best absorbed on an empty stomach before your meal, ideally 15 to 30 minutes ahead.
If you miss a dose, take your levodopa as soon as you remember. In late Parkinson's, you may notice that timing becomes essential. You may feel unwell or off when you are late.
Common side effects:
Nausea
Stomach upset
Low blood pressure
Sleepiness between 1 and 2 hours after taking it. If you notice this, avoid driving, drinking alcohol, or operating heavy machinery. These activities can be dangerous if you are drowsy.
Hallucinations (seeing things that aren't there) are a problem in the later stages of the disease.
Motor fluctuations (The rise and fall of levodopa's effects). As time goes on, you may notice periods of the day when your medication is working less well. Most often, "off" times start just minutes to hours before your next dose is due. Off periods are related to how long levodopa's effect lasts in your body. As this period changes, you and your doctor must work together to change your treatment approach. If you notice on and off periods, Keep careful track of when this happens. If you understand your pattern, it will be easier for your doctor to offer options to adjust your treatments.
If it is hard to remember, use a diary to keep track of:
how long exactly it takes for your medication to wear off
how long it takes for the next one to kick in any other changes or patterns that happen during the day
Your doctor will adjust your medication dose
Dyskinesia (Increased movements):
Some people may notice increased movements, such as twisting, twitching
Usually, it appears about 1 to 2 hours after you have taken your medication.
Usually, it does not bother you, and you may not even be aware that you have it.
More serious dyskinesia can be tiring or make you lose balance.
Dyskinesia is a sign that your medication works, but perhaps too well.
All Parkinson's medications can cause increased movements, but since levodopa is the most effective medication, it tends to cause this the most.
A lower medication dose should help keep your dyskinesia in check. However, this can bring back the "off" periods and the other motor problems you used to have. For this reason, your dose may need more careful fine-tuning.
Dopamine agonists:
These medications do not work as well as levodopa in controlling Parkinson's symptoms. However, they do have a more stable and long-lasting effect.
Pramipexole, Ropinirole, and Rotigotine. Pramipexole and ropinirole are pills. Rotigotine is a patch. Your skin will absorb the medication from the patch.
Have the same side effects as levodopa.
Leg swelling
Some people may develop strong urges that are hard to control. This could include uncontrollable desires to gamble, shop, or have sex. As with all side effects, it will go away quickly when you stop the medication. If you do not notice this problem, ensure your family or caregivers know this could happen. Ask them for their help in watching for it.
MAO and COMT inhibitors:
These help keep dopamine in the body for a longer period by slowing down the process of breakdown.
2 types of medications have this effect on dopamine: MAO inhibitors and COMT inhibitors
MAO inhibitors, e.g. selegiline, rasagiline (or Azilect).
Side effects: You may notice nausea and trouble falling asleep (especially if taken in the late afternoon or evening). MAO-inhibitor medications may raise your blood pressure when taken with foods that contain extremely high amounts of tyramine. This is found in cured meats, aged cheeses, and wine, to name a few.
COMT-Inhibitors (e.g., entacapone): COMT-inhibitor medications slow down COMT, a substance in your body that breaks dopamine down in your brain. They only work on levodopa. For this reason, they are usually given with levodopa, either as a separate pill (e.g., Comtan) or in a levodopa-composition pill (e.g., Stalevo).
The side effects of COMT-inhibitor medications are the same as when you are taking higher doses of levodopa. You may notice dyskinesia or nausea. This medication can also sometimes cause diarrhea. Entacapone may also make your urine a brownish-orange colour. This is harmless.
Other medications for motor symptoms:
Amantadine is mainly used for dyskinesia (increased movements). Amantadine can relieve this problem quite well for some people without bringing back other motor symptoms.
Amantadine generally has less of an effect on slow movement and tremor.
It may help with fatigue in some people.
The side effects of this medication are similar to dopamine medications. Hallucinations and nausea are the most common. Amantadine can also cause this bluish lace-like colour change ( Livedo reticularis ) that can appear over the calves of your legs. It can look a bit odd; however, it is harmless.
Anticholinergics:
Anticholinergic medications are sometimes used to control Parkinson's motor symptoms. For unclear reasons, they seem to work best on tremor. The most common of these medications are trihexyphenidyl (Artane) or benztropine (Cogentin). Anticholinergic medications lower the amount of acetylcholine in your brain. The most common are Blurred vision and Memory loss, which are the most critical side effects of these medications. This happens more often in older people. For this reason, your doctor might only suggest this medication if you are under 50 years old.
Unique therapies for Advanced Parkinson's:
After you have had Parkinson's for many years, your doctor may suggest other treatment options. These special therapies are not considered for people at the early stages of the disease.
Deep brain stimulation (DBS):
This treatment involves surgery. The electrodes are placed in one of your brain's movement control centers, and the wires are connected to a pulse generator device placed in your chest, just under the skin. Once your wires are placed, you will need regular check-ups with your deep brain stimulation care team. From time to time, your team may need to adjust the device and your Parkinson's medications.
Deep brain stimulation can be thought of as electronic 24/7 levodopa. For this reason, it will not improve the symptoms that levodopa does not help. Many patients eventually undergo deep brain stimulation treatment on both sides of their brain.
Deep brain stimulation is not for everyone. This treatment is reserved for a small group of carefully selected people with Parkinson's. Many things (e.g. your response to levodopa, mood, memory loss, your current ability to reason, think and understand, and more) are reviewed in this decision. This treatment does not seem to help people who are over 70 years of age. As with any brain surgery, there is a chance of complications after deep brain stimulation surgery. These would include brain hemorrhage, stroke, and infection. Severe, long-lasting complications are not common. However, some people can have cognitive difficulties or speech problems.
Continuous medication: Continuous medication is a treatment approach that skips the stomach altogether. Duodopa is a (levodopa-carbidopa) combination medication in gel form. This medication can be delivered directly to your small intestine. Continuous medication is delivered through a pump connected to a needle under your skin. This generally has a similar effect and side effects as Duodopa.
The pump can be programmed to your needs, with the option to add extra doses if you have unexpected off times. You wear the pump constantly throughout the day and attach containers of medication (cassettes) to it. This tube is connected to a pump, which delivers low and constant doses of the Duodopa medication. The pump is used for about 16 hours daily, and cassettes are changed daily. After placing it in your small intestine, the Duodopa system will need continuous care. It will also need to be programmed regularly by a qualified professional. In general, this treatment requires more care than deep brain stimulation. Continuous medication is not for everyone. Sometimes, the skin around the tube's insertion site can become infected. The tube can also be twisted, blocked, or clogged, especially if not flushed frequently. Usually, you will have regular visits with a specialized nurse to help with these issues. The effects and side effects of continuous medication are the same as levodopa. However, you may notice that your side effects are milder. Also, you may find that you have less dyskinesia (increased movements) compared to when you were taking levodopa as a pill. This is because your brain is receiving a much smoother and more constant medication delivery this way.
References: 1. Parkinson Canada - Treatments
