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Sinemet Worked in Reverse


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#1 JohnL

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Posted 05 February 2012 - 01:08 AM

My wife began experiencing unilateral tremors (Right Hand) 3 years ago beginning immediately after hip replacement surgery. Her right hand was the site of an I.V. drip and became numb during the post op recovery. Within 5 days, the numbness subsided and the tremor came.

Also, she had injured her right shoulder several years before the operation and re-injured it twice over the years, the last time being about 3 years before the hip operation. (She was exhibiting no symptoms of shoulder injury however prior to the hip operation.)

Her Internist told her that the tremors were probably a result of nerve injury brought on by the I.V. however the internist suggested a consult with a Neurologist just to be certain.

The Neurologist evaluated her and told her he suspected PD, based on the tremor and her gait. My wife explained that the tremors showed up immediately after the surgery and briefed the Neurologist on both what had happened with the I.V. as well as the history of shoulder injury. She pointed out the she had had a hip replacement and added the fact that the surgeon has increased the length of her leg so that each was the same length (about 1 one inch difference from the way she had been all her life) so she still didn't walk the same way she had in the past.

The Neurologist told her that the "Gold Standard" for determining if she actually did have PD was to take a slowly increasing dose of Sinemet and observe if the symptoms disappeared at some point.

My wife began the regime and at low dosages there was no change. About midway through the test, she became very "anxious" and "nervous". 3/4 of the way through her tremor amplitude increased greatly and she came to feel as if she was "speeding up" as if she had taken some sort of stimulant.

The Neurologist ramped her back down and we revisited him for another consult. He now said that although the Sinemet didn't work as expected, my wife still had PD.

I was along this time and asked him why, if Sinemet was the "Gold Standard" and it would be proof positive that she had PD if the tremors stopped at some point when taking the drug, how could it be that he was still diagnosing her as a PWP when the result was exactly opposite what he said would happen?

He had no answer but stuck to his guns.

He prescribed Azilect since Sinemet wasn't working properly. She is now 6 months into a 1mg/day regime of Azilect with no change to her tremor symptoms.

She has none of the other typical PD symptoms - no freezing, swallowing difficulty, intellectual issues, nor speech problems.

We both realize that we are not wanting to accept a diagnosis of PD and are not qualified to make a diagnosis ourselves. But we are totally confused about what happened with the Sinemet test given what we were assured the test would confirm whether or not she had PD due to the cessation or continuation of her tremor.

So, with this rather long winded background, two questions:

Have you ever heard of Sinemet exacerbating PD tremors instead of nulling them out?

Should we consult a movement disorder specialist (the Neurologist was not an MMS)in your opinion?

Thank you very much.

#2 MComes RPH

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Posted 16 February 2012 - 09:27 AM

First, not to "knock" the Dr, but too many issues occured prior to diagnosis that could mimic 2 of the 4 primary PD symptoms.
Primary symptoms of Parkinson’s disease:
1-Bradykinesia – slowness in voluntary movement such as standing up, walking, and sitting down. This happens because of delayed transmission signals from the brain to the muscles.  This may lead to difficulty initiating walking, but when more severe can cause “freezing episodes” once walking has begun.
2-Tremors – often occur in the hands, fingers, forearms, foot, mouth, or chin. Typically, tremors take place when the limbs are at rest as opposed to when there is movement.
3-Rigidity – otherwise known as stiff muscles, often produce muscle pain that is increased during movement.
4-Poor balance – happens because of the loss of reflexes that help posture. This causes unsteady balance, which oftentimes leads to falls.
The Dr is correct that sinemet is the "gold standard" to diagnose PD and is correct probably 99.9% of the time. Here is why I say that you should seek a second opinion.
1- the tremor and numbness are probably due to either a "nicked" nerve during IV injection (very rare) or a "pinched" nerve or inflammation causing pressure on the nerve after the shoulder surgery. People forget that the shoulder is unlike any other joint due to the fact that it just doesn't move up and down, it also rotates, pulls, and pushes at all different. So, recovery for shoulder surgery is a long process and I have personally seen people for up to a couple years have numbness, tingling, twitching, and mild tremor in the affected hand or arm. Inflammation in the area may be putting pressure on the nerves, so if she can tolerate motrin, she should try that.
2- as far as the "gait" issue, if someone had hip or leg surgery yesterday or 10 years ago, they will probably walk different. Either because the leg/hip still has issues or the other leg is trying to compensate for the pain in the other leg which will cause people to walk differently. This, at least to me, may appear to be this issue. Like I said, I did not see her.
3- The sinemet test- if some has PD and does the sinemet titration and the symptoms go away......probably, moat likely, absolutely certain...PD. There is also another, much more fun way to see if it is PD. If someone who is believed to have PD and they drink alcohol, if the tremor DOES NOT go away....PD. Yes, this is true. If the tremor goes away...usually no PD. I told my Dr I would rather try that way. He declined.
4- what effects will happen if someone takes sinemet qnd the DO NOT HAVE PD. The aymptoms would be the same if some who does have PD took too much. Here are some of the effects.
1- Confusion, agitation, anxiety
2- Insomnia, restlessness, sleep disturbances
3- Involuntary body movements (dyskensia)
4- Possible nausea and/or vomiting depending on amount of sinemet
6- Posaible rapid heart rate (tachycardia)-dose dependent
7- Low blood pressure (hypotension) or high blood pressure (hypertension).
I will tell you, as most with PD will, that too much dopamine is one of the most horrible geeling in the world. It is like you can geel an erupting volcano inside you. It also feels like ants crawling through your bones. Not a fun experience.
So, my advice is to seek out a second opinion from a movement disorder specialist(MDS). If there is not one in your area, another neurologist would be ok. I truly think an MDS is the way to go.
You may want to speak with the current Dr and ask what other major or minor symptoms he may have seen. If he saw 10 minor symptoms and these 2 major symptoms (which can be explained), then he may be on to something. But just rationalizing it out and a negative sinemet titration, definiyely seek out an MDS.
keep me updated.

 

My wife began experiencing unilateral tremors (Right Hand) 3 years ago beginning immediately after hip replacement surgery. Her right hand was the site of an I.V. drip and became numb during the post op recovery. Within 5 days, the numbness subsided and the tremor came.

Also, she had injured her right shoulder several years before the operation and re-injured it twice over the years, the last time being about 3 years before the hip operation. (She was exhibiting no symptoms of shoulder injury however prior to the hip operation.)

Her Internist told her that the tremors were probably a result of nerve injury brought on by the I.V. however the internist suggested a consult with a Neurologist just to be certain.

The Neurologist evaluated her and told her he suspected PD, based on the tremor and her gait. My wife explained that the tremors showed up immediately after the surgery and briefed the Neurologist on both what had happened with the I.V. as well as the history of shoulder injury. She pointed out the she had had a hip replacement and added the fact that the surgeon has increased the length of her leg so that each was the same length (about 1 one inch difference from the way she had been all her life) so she still didn't walk the same way she had in the past.

The Neurologist told her that the "Gold Standard" for determining if she actually did have PD was to take a slowly increasing dose of Sinemet and observe if the symptoms disappeared at some point.

My wife began the regime and at low dosages there was no change. About midway through the test, she became very "anxious" and "nervous". 3/4 of the way through her tremor amplitude increased greatly and she came to feel as if she was "speeding up" as if she had taken some sort of stimulant.

The Neurologist ramped her back down and we revisited him for another consult. He now said that although the Sinemet didn't work as expected, my wife still had PD.

I was along this time and asked him why, if Sinemet was the "Gold Standard" and it would be proof positive that she had PD if the tremors stopped at some point when taking the drug, how could it be that he was still diagnosing her as a PWP when the result was exactly opposite what he said would happen?

He had no answer but stuck to his guns.

He prescribed Azilect since Sinemet wasn't working properly. She is now 6 months into a 1mg/day regime of Azilect with no change to her tremor symptoms.

She has none of the other typical PD symptoms - no freezing, swallowing difficulty, intellectual issues, nor speech problems.

We both realize that we are not wanting to accept a diagnosis of PD and are not qualified to make a diagnosis ourselves. But we are totally confused about what happened with the Sinemet test given what we were assured the test would confirm whether or not she had PD due to the cessation or continuation of her tremor.

So, with this rather long winded background, two questions:

Have you ever heard of Sinemet exacerbating PD tremors instead of nulling them out?

Should we consult a movement disorder specialist (the Neurologist was not an MMS)in your opinion?

Thank you very much.


Best of health,
Mark R. Comes R.Ph.
"Ask The Pharmacist"
www.parkinson.org




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