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Dr. Okun

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Everything posted by Dr. Okun

  1. Dr. Okun


    It is variable across patients and different strategies work for different patients. The key is monitoring.
  2. I don't buy into all the formulas as being exact. I follow symptoms. Reasonable to use formula and go slow, but titrate up or down by symptoms as it is just a guess.
  3. Dr. Okun

    Fatigue after DBS battery replacement

    Yes, it is possible after battery surgery to experience fatigue from the surgery, anaesthesia or other factors. If it is linked to the surgery and does not resolve to baseline in a few weeks probably best to alert your doc.
  4. Dr. Okun

    Does your size matter?

    Excessive sleepiness, dyskinesia, high energy level are all symptoms that may emerge in some patients with higher doses of Sinemet.
  5. Dr. Okun


    Everyone is different. If you try lower doses of Sinemet/Madopar and increase agonists you could still have side effects so it would need to be monitored. Everyone is different so it may work in some cases.
  6. Dr. Okun


    You should definitely have a chat with your care team and see what they think.
  7. Dr. Okun

    Question about Link between dopamine and testosterone

    Great question. Our group actually studied this and we could not find a relationship between testosterone level and levodopa (Sinemet) dose.
  8. Dr. Okun

    Does your size matter?

    Great question. Sometimes the dose must be adjusted over time and it is not always higher.....sometimes it is lower. If there are symptoms like dyskinesia for example you and your doc may try lower doses....
  9. Dr. Okun


    It really depends on what your practitioner is comfortable with.....all work and must be titrated and monitored for side effects (ICD's etc.). CR will sometimes peak less in the bloodstream and lead to less sleepiness. Sometimes a lower dose of Rytary can be found....it is trial and error.
  10. Dr. Okun


    Great questions. I generally do not aggressively stop meds after DBS as it can lead to anxiety, depression, apathy and other symptoms....I may try gentle reductions but do it slowly and sometimes restoring meds helps anxiety. As I have read through posts sometimes the solution is to reduce time between l-dopa doses to treat off-time anxiety. 1. How do you and patient decide what is the better option between anti-anxiety meds or reduce time between sinemet doses? -I almost always optimize Parkinson meds first and move doses closer together and find the right dose as in many cases it is simple wearing off. 2. How does anxiety typically progress over the course of Parkinsons disease? Are there progressive treatments? -It is highly variable patient to patient but in broad strokes as you wear off between doses this seems to make anxiety symptoms worse. 3. What is the biological cause of anxiety in PD? Are there treatments based on biology of PD anxiety? -We believe it is a biological change from degeneration of brain regions important to non-motor function. 4. Can certain foods trigger anxiety? Foods to avoid? -Not sure on that one, but if they do I would think a rare cause. Thanks so much for all you do. I love your forums and helpfulness. -Totally happy to help. Also, once I adjust meds and DBS (if you have it) I also consider cannabinoids for anxiety.
  11. Dr. Okun


    My pleasure.
  12. Dr. Okun


    I am sorry this must be frustrating. A DAT scan may set your mind at ease.
  13. Dr. Okun

    Sinemet and Amantadine

    Great question. I do not know of a study examining this question, but in my experience it doesn't make a difference; except that taking before Sinemet may help with dyskinesia in some cases. It also matters if you take immediate release (3 times a day) vs. extended release (once a day).
  14. Dr. Okun

    Endoscope procedure

    My pleasure.
  15. Dr. Okun

    Sinemet & Dyskinesia Question

    Thanks and good luck. Remember that 1 in 5 Parkinson patients get demoralized and it may not be depression. Consider that in some but not all cases counseling with a licensed clinical social worker may be helpful (or psychologist).
  16. This is a tricky case, and I will give a shot to few answers: I could try to keep the dose of 2 tabs of Sinemet but apply it more often - every 2.5 hours (instead of 3 hours) starting at 7 am and continue to 10 PM when I go to sleep. --Sometimes if you are wearing off between dosages this may help. 1) Is this the right approach to try in my case ? What do you think ? -There is no one right approach; you and your doc will need some trial and error. It is possible that Mirapex just simply works better for you and you could consider that in your decision making. Of course weaning agonists should be slow to avoid withdrawal and some people exposed to agonists have a hard time substituting Sinemet. 2) What could you recommend to try to optimize my Sinemet with Neupro medication? -I think you are on the right track but you may ask your doc about lowering the Neupro so you are not sleepy and looking at med intervals and doses of Sinemet. 3) What else would you recommend to try at this point? -You could go back to Mirapex, try a Duopa pump or consider DBS. 4) Could it be that Mirapex ( 1 mg X 3 times daily) was providing a stronger support compare to Neupro 6 Mg/24h patch at the day time ? -Yes -Hope that helps and good luck.
  17. Dr. Okun


    Personally I always think when you have tremor and neurological symptoms a neurology consult is a great idea. Mirtazapine is an antidepressant but can help sleep and tremor in some patients (perhaps the anticholinergic effect). If there is confusion between psychiatric symptoms and PD see a neurologist and in some cases a DAT scan can help.
  18. Dr. Okun

    Is my Madopar working or not?

    You are likely being too ginger with the dose and you and your doc need to titrate the dose up slowly to the desired effect. Your doc can follow your symptoms in the office using a Parkinson scale like the UPDRS.
  19. Dr. Okun

    Sinemet and Amantadine

    We use the amantadine 3 times a day spread out or the extended release. You may also try 1.5 sinemet every 4 hours as an alterative. Ask your doc and good luck.
  20. Dr. Okun

    RLS n pregnancy n YOPD

    I would visit with the pharmacist on this one and check FDA labeling for pregnancy on all drugs....but keep in mind that not much is known. Sinemet is felt by many experts to be the safest. After you get out of the first and second trimesters some people will add other drugs in.... If you don't want to use an agonist some people use folic acid plus gabapentin later in the pregnancy but again, not enough data.... P.S> There is a tale that a bar of ivory soap under your bed pillow stops RLS (if that works it has no pregancy risk!). Pregnancy outcomes following gabapentin use Results of a prospective comparative cohort study Hisaki Fujii, MD, Akash Goel, BSc, Nathalie Bernard, PhD, Alessandra Pistelli, MD, Laura M. Yates, MBCHB, Sally Stephens, PhD, Jungyeol Y. Han, Doreen Matsui, MD, Fatwa Etwell, BSc, Thomas R. Einarson, PhD, Gideon Koren, MD, and Adrienne Einarson, RN Author information ► Article notes ► Copyright and License information ► Disclaimer This article has been cited by other articles in PMC. This article has been cited by systematic reviews in PubMed. Abstract Objectives: Our objectives were to 1) determine whether first-trimester use of gabapentin is associated with an increased risk for major malformations; 2) examine rates of spontaneous abortions, therapeutic abortions, stillbirths, mean birth weight and gestational age at delivery; and 3) examine rates of poor neonatal adaptation syndrome following late pregnancy exposure. Methods: The study design was prospective. Women were included who initially contacted the services between 5 and 8 weeks with a comparison group of women exposed to nonteratogens, collected in a similar manner. Results: We have data on 223 pregnancy outcomes exposed to gabapentin and 223 unexposed pregnancies. The rates of major malformations were similar in both groups (p = 0.845). There was a higher rate of preterm births (p = 0.019) and low birth weight <2,500 g (p = 0.033) in the gabapentin group. Among infants who were exposed to gabapentin up until delivery, 23 of 61 (38%) were admitted to either the neonatal intensive care unit or special care nursery for observation and/or treatment, vs 6 of 201 (2.9%) live births in the comparison group (p < 0.001). There were 2 cases of possible poor neonatal adaptation syndrome in neonates exposed to gabapentin close to delivery, compared with none in the comparison group, although it must be noted that these infants were concomitantly exposed to other psychotropic drugs. Among the women who took gabapentin, the major indications were pain (n = 90; 43%) and epilepsy (n = 71; 34%); the remainder were for other indications, mostly psychiatric. Conclusion: Our results suggest that although this sample size is not large enough to make any definitive conclusions, and there was no comparator group treated with other antiepileptic drugs, gabapentin use in pregnancy does not appear to increase the risk for major malformations. This finding and the increased risk for low birth weight and preterm birth require further investigation.
  21. Dr. Okun

    Endoscope procedure

    We try not to use any of these drugs but in circumstances when we do use them, a little propofol if properly monitored or versed seems to be a good option. In our practice we do not use demerol.
  22. Dr. Okun

    Sinemet & Dyskinesia Question

    Bill, you can certainly develop dyskinesia within 2 years (possible but not common). I am not sure by your description you have dyskinesia. It would be better to videotape your movements, note your last dose of Sinemet and how much (timing on the video) and show it to a neurologist experienced in Parkinson and LBD. If you can;t find one close you can try our help line 18004PDINFO.
  23. You may also seek a sleep study as sleep apnea may be contributing to your issues.
  24. Dr. Okun

    Steerable DBS

    I think we need more data and that certainly it has the potential to do great things. Side effects such as pulling, swallowing or voice would be at the top of my list. Also, gait and balance. Not sure if it will address cognition or ICD as well or if at all. Again, need data. Most important is that we implant the lead in the best spot as a well placed lead will be the first step...
  25. Dr. Okun

    Changing from mirapex to Artane

    It probably doesn't matter. In my practice we use immediate release.