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Post of the Week:Factors to consider when starting treatment


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#1 Dr. Fernandez

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Posted 17 November 2009 - 03:13 AM

I am newly diagnosed with Parkinson’s disease, what factors are considered by my doctor when starting me on a medication?

You ask a very important question. Several factors require consideration when initiating symptomatic drug therapy in Parkinson’s disease. The choice of pharmacotherapy depends on the patient’s age, degree of disability, and cognitive status, as well as the impact of dosing, possible impact on the patient’s employment, domestic responsibilities, and lifestyle. Potential drug side effects must also be considered. Thus there are a lot of factors to consider!

The patient’s age is an important factor in predicting how well certain medications might be tolerated, as the risk of developing dyskinesia and motor fluctuations, especially with levodopa use, increases with earlier/younger onset Parkinson’s disease (most especially those who get it before 50 to 60 years old). Dopamine agonists, which delay the risk of dyskinesia and end-of-dose wearing off, may be offered as a first-line treatment option for younger patients. However, in older patients (which in our field means greater than 70 years old), the dopamine agonists have a higher risk for producing psychiatric and cognitive side effects. In addition, dopamine agonists have a complicated initial titration schedule before a therapeutic dose can be achieved. They require multiple dosing throughout the day, making the use of these agents challenging for many patients but especially so for patients 70 and older, who may be on several therapies for other conditions. Morover, the elderly patient is less likely to develop motor fluctuations and dyskinesias compared to the younger patient. Thus, in the currently published treatment algorithm, it is suggested that for the older patient, levodopa may be a better choice as initial first-line therapy compared to dopamine agonists.

The good news is that recent data suggest that an alternative option for initial monotherapy for early PD patients is rasagiline, a selective monoamine oxidase type B (MAO-B) inhibitor that offers effective control of symptoms and appears to be have a much lower incidence of the dopaminergic side effects seen with dopamine agonists and levodopa.

In one large placebo-controlled, multi-center clinical trial, after 5 years of levodopa use and as Parkinson’s disease progressed, about 50% of patients who were given levodopa from the onset developed motor complications compared to only 20% of patients who were first started on dopamine agonists for their early symptoms. However, the traditional view that treatment of Parkinson’s disease should begin only when symptoms become functionally significant has been challenged by some recent studies suggesting that initiation of treatment at the time of diagnosis results in better clinical outcome later in the course of the disease.

The patient’s perception of their level of disability and its impact on their lifestyle is also a driver of initial choice of therapy. Patients at the early stage whose major presenting symptom is tremor and who have minimal slowness or stiffness may respond to drugs such as anticholinergic agents or amantadine before their symptoms worsen. Rasagiline, selegiline, dopamine agonists or levodopa may be added as the disease progresses.

The potential of therapies to produce untoward side effects based upon the patient age and comorbid conditions is another important factor in choosing initial Parkinson’s disease therapy. As mentioned, dopamine agonists are not a good first choice in older patients due to concerns of leg swelling, cognitive impairment, and hallucinations. In patients in whom excessive sleepiness and drowsiness may affect daily activities, dopamine agonist use may also not be appropriate.

Yours,
Hubert H. Fernandez

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Posted 17 November 2009 - 08:43 AM

Good recap ... thanks!

Rich

#3 Dr. Fernandez

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Posted 19 November 2009 - 07:37 PM

You are welcome!
Hubert H. Fernandez

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Posted 21 November 2009 - 11:01 AM

Let me pull out a small portion of your post that is very important - the fact that motor complications occurred more often with the patients on sinemet than on the dopamine agonists after five years.

For those just beginning therapy you must realize that many of these motor complications can be very very minimal. I for example will have movement of my feet first thing in the morning when my sinemet hits my brain. The movement is minimal and causes no problems. No the dopamine agonists did not cause a problem like this but they caused me to faint at least 15 times a day. I did not change because I was afraid to take dopamine.

My point is - don't be afraid to try sinemet (dopamine). It really does work amazingly well (it stopped ALL my PD problems from drooling to freezing to tremor) and the side effects can be controlled one way or another by adjusting dosage and adding or subtracting other things. If the dopamine agonists work for you - GREAT. But if they don't - DON'T WAIT. Get on sinemet. I lost three years of my life because I waited too long to get on dopamine because of the older articles that said that taking it caused the disease to progress faster. From what I understand this is no longer thought to be true.

Good luck all!

#5 Dr. Fernandez

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Posted 21 November 2009 - 05:46 PM

Thank you for your comments!
Hubert H. Fernandez

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Posted 30 January 2010 - 07:42 AM

I am 54 years old and was diagnosed with Morbus Parkinson while on a work assignment in Germany - We lived previously in Orlando. The diagnosis was in October 2009. I had been experiencing some minor tremor in my right thumb for about 9 months prior to the diagnosis. I wrote the tremor off as maybe a result of stress. In August I thought I pulled a muscle in my left leg and also thought nothing of it and that it would go away in a few days. After about 10 days my wife made me go to a Doctor and the diagnosis was Bursitis. The Doctor however advised that I see a Neurologist because he suspected that I might have Parkinson's. That was the beginning of seeing 3 different Neurologists. The first one checked my motor functions briefly and gave me a short memory quiz and the resulting diagnosis was Chronic Encephalitis and scheduled a Spinal Tap. I was a bit shocked by the diagnosis and hesitated to go ahead with a spinal tap. So on to the second Doctor who as I learned later had experience with Parkinson's. He at first put me on 10 mg Motillium and Madopar LT(Levodopa) 100 mg. My initial reaction to taking this medication was that I felt better after taking the Motillium and worse after taking the Madopar. The Doctor scheduled me for Hospital Inpatient to try a Dopamine Agonist Neupro or Rotigotin. The first day he injected a high dose form of Dopamine Agonist - injected into my stomach. I had a pretty severe reaction resulting in Nausea and resulting in regurgitating
along with light headedness and did everything I could do to keep myself from passing out. I am not certain if this is typical for preparing a patient for taking a Dopamine Agonist - can you comment on this ?
I am now on 4 mg Neupro Patch per day and it has helped with some coordination problems but has not completely eliminated my Tremor. In addition, I have begun exercising at a local training center and have found it to be very good for my overall feeling of well being. I do notice that at certain angles of weight lifting I experience a shuttering of my whole body. Is this also a symptom of Parkinson's?

#7 Dr. Fernandez

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Posted 30 January 2010 - 05:12 PM

It does sound like you have parkinsonian symptoms....probably PD. But obviously, it would be hard to say without seeing you.

I am not sure about the therapy that you tried...they are not something we typically do here in the US, but it is also hard to say given that I don't have the full story and I can't really see what your doctor saw for them to consider the treatments given to you.

It is assuring that you are feeling a little better with the neupro. I think the reason why it has not controlled your tremors better is because you are at a very low dose...?

Exercise is great...but always be safe and don't overdo it.

Yours,
Hubert H. Fernandez

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Posted 31 January 2010 - 05:20 AM

Thank you Dr Fernandez for your quick reply.
I now am only on the Neupro - which is administered via a patch at a dose of 4 mg per 24 hours. I understand that this medication was for a time available in the US but was recalled. There were problems with the medication crystallizing - but that seems to have been corrected by the manufacturer. Other tests that were performed were a CAT Scan & MRI - both without findings.

PS I was also diagnosed in 2002 with Osteopenia and had been taking Actonel up until last year when my German Doctor took me off of it, saying that at my Age, weight training would be the best for me. I was also started on Testosterone replacement while in the US and I continue that here in Germany. All of these previous diagnosis seem to be related to PD from what I have learned.


When I return to the US - Orlando - in May 2011 or perhaps during my next visit home I would be interested in making an appointment with you.

#9 Dr. Fernandez

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Posted 31 January 2010 - 06:06 PM

Anytime.

I, or any member in our team will be happy to see you.

Good luck!
Hubert H. Fernandez

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Posted 01 March 2010 - 10:09 AM

It is assuring that you are feeling a little better with the neupro. I think the reason why it has not controlled your tremors better is because you are at a very low dose..http://www.buengolpe.com

#11 Dr. Okun

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Posted 01 March 2010 - 11:06 AM

To clarify dose is not always the answer but is always a possibility.
Michael S. Okun, M.D.
Author of the Amazon Bestseller Parkinson's Treatment: 10 Secrets to a Happier Life
National Medical Director | NPF
UF Center for Movement Disorders & Neurorestoration
Read More about Dr. Okun at: http://movementdisor...hael-s-okun-md/
or Visit Parkinson's Disease treatment and research blogs at:
NPF's What's Hot in Parkinson's disease
or his parkinsonsecrets.com blog for treatment tips

#12 carruthers209

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Posted 18 March 2010 - 10:21 PM

On the home page of the NPF several months ago there was a reference to heart medication statins being a possible drug that not only slowed the Parkinson's but could reverse the disease. The Science Daily.com on January 23, 2010 had an article titled "Common Heart Medications May Also Protect Against Parkinson's Disease. Do you think that this newly diagnosed Parkinson's patient could possibly benefit from pursuing the use of statins? Is there a point to more advanced Parkinson's patients pursuing statins as a helpful drug for the disease? Are there counter indicators in the research that might preclude the use of statins? Thank you in advance.

#13 Dr. Okun

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Posted 04 April 2010 - 02:08 PM

At this point in time there is no clear evidence if you have PD already that taking a statin will be helpful. Statins can have side effects including liver and GI issues and also muscle aches. We need more studies.
Michael S. Okun, M.D.
Author of the Amazon Bestseller Parkinson's Treatment: 10 Secrets to a Happier Life
National Medical Director | NPF
UF Center for Movement Disorders & Neurorestoration
Read More about Dr. Okun at: http://movementdisor...hael-s-okun-md/
or Visit Parkinson's Disease treatment and research blogs at:
NPF's What's Hot in Parkinson's disease
or his parkinsonsecrets.com blog for treatment tips




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