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Dr. Okun

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Everything posted by Dr. Okun

  1. This is not in my opinion an adequate trial of dopamine. Sinemet needs to be pushed up to 3 tabs per dose in multiple doses before concluding tremor is unresponsive. Also, the features of PD need to be documented on a scale (UPDRS ideally) as sometimes many other features improve and not tremor. Some people will also later add dopamine agonists and of course DBS is a great option for tremors that do not respond to meds.
  2. DBS, Hip/leg Pain

    The speech is commonly associated with DBS surgery (worsening and more worsening with more leads; 2 greater than 1). The pain would be uncommon as a DBS manifestation. You could temporarily and with doctor supervision turn off the devices and see what gets better. Usually we involve an orthopedist and a neurosurgeon to sort out whether this is bone pain, nerve pain or both and what the options are...
  3. dbs and duopa pump

    Yes, we have patients with both therapies. There was also a recent study and about half of patients in that study who added Duopa had meaningful improvements but half didn't. I think you should focus on the symptoms you want improved and discuss with your doc whether adding the pump will help. In general medication fluctuations despite very close medication intervals and a lot of "off" time following DBS may trigger the discussion in our clinic. We may also ask the question as to whether the DBS leads are in the right place. Hope that helps you on your journey.
  4. Can dry eyes be treated.

    I am not sure of a relationship between dry eyes and hallucinations but in the office we treat the two problems differently. Here are a few tips. PD patients blink less and may have dry eyes. Eye drops are usually helpful. PD patients often have double vision and the eyes at close distances do not work together well (convergence insufficiency). Sometimes a neuro-opthalmologist can help (prism glasses). Hallucinations and psychosis we treat through checking for urinary and other infections; optimizing medications, and in some cases adding a medication. This should be a complex discussion with the neurologist or psychiatrist. Hope that helps.
  5. Narcolepsy, Cataplexy, Parkinson

    Narcolepsy and cataplexy are completely different from Parkinson. If you truly have both it has been our experience that the PD meds including Sinemet are safe. We do however recommend that your sleep study and sleep expert confer with your PD expert to make sure the diagnosis is correct and managements can be balanced.
  6. Constipation

    Thanks for the post.
  7. Great question. Response to tremor on a dopamine challenge does not inform the diagnosis of Parkinson's disease. It turns out 20-40% of patients may have an incomplete response to tremor after dopamine. Also, in your case 1 pill may indeed not be enough. We usually recommend seeing a movement disorders trained or experienced neurologist if available and titrating the dose slowly looking for improvement. Everyone is different and the tremor may likely improve or resolve at higher doses. I hope that is helpful.
  8. Predisposed to Parkinson's

    I lost the thread from the question, but I can say that "yes" I do not know in many cases whether genetic or not; and why it sometimes skips people in the same family. Sometimes it is a characteristic of the type of PD gene, and sometimes the person just doesn't inherit the gene. In some cases we can't find a gene. I lot I (we) don't know. Apologize as I can't see previous question.
  9. Anamnestic Response

    There seems to be a predilection with age and with PD in both sexes for urinary infections. I generally partner with a urologist to try to address these issues.
  10. Help with questionable diagnosis

    My pleasure.
  11. Nutrition and PD

    My pleasure.
  12. Constipation

    Constipation is a common symptom in PD and can be disabling and can worsen other PD symptoms. I would verify your thoughts on constipation and also recommend aggressive treatment.
  13. Buzka

    I have not seen this as an effect of sinemet. Amantadine I have seen this issue.... There can sometimes be a skin allergy to yellow dyes in pills, but this rare. I would in short not assume it is related.
  14. PD and desired weight loss

    There are not yet really good studies to tell people the best foods to eat or avoid in Parkinson. I tell my patients to eat a healthy diet. I also tell them that a few patients will have trouble absorbing meds and sometimes giving the meds 30-60 minutes to absorb before eating is helpful. Occassionally avoiding or limiting protein is helpful.
  15. Safety Criteria

    I try not to make absolute recommendations, and I like to see patients regularly and discuss limits based on their examination and history. Ladders and chainsaws I do however tell patients it is best to not use them (safest).
  16. Nutrition and PD

    I have read this study and my personal opinion is that the methods and data do not support the conclusions and I am not recommending to make changes in any of my patients based on this study.
  17. Timing of Sinemet vs increased dose

    Not aware of what exactly you seek, but can tell you that finding the lowest dose that controls symptoms and the right interval are the key. Nothing alarms me about your story and I would continue to adjust based on symptoms.
  18. Xadago

    Personally I recommend to my patients to take medications, to exercise and to see their doc several times a year. I like PT, OT and speech/swallowing and I am aggressive with a team approach. I choose meds based on the situation and patient, but in your case I do not agree with your philosophy for not taking them. I would start with a MAO-B drug (doesn't have to be Xadago). I then add either an agonist or levodopa and I monitor carefully for side effects. We see few side effects from MAO-B, but the dopaminergics may have some such as impulse control.
  19. Parcopa getting washed out along with stool

    I doubt it is washed out in the stool but you may have absorption problems and in these cases sometimes DBS or Duopa pumps help. But before that see your doc and look at adjustments in your med dosages and also in timing. Good luck. Remember also some PD patients have H Pylori and other GI issues that need to be addressed to help absorption of meds. Seeing a GI doc can be helpful and a gastric emptying study may be indicated in some cases.
  20. Sleep Problem

    We always recommend to see your doc; wean off agonists and in some cases the levodopa (Rytary) needs to be reduced. We also get a sleep study and we look at all the meds.
  21. Predisposed to Parkinson's

    It is my view that this is incorrect. About 10% are known genes and some peoplle with known genes do not manifest during life. About 90% it is not clear the cause or causes. There is a lot of research in this area and a lot of debate...thus I express my opinion. Hope that helps.
  22. Anamnestic Response

    Antibiotics and infection can both worsen PD symptoms and in most cases over time the old baseline functioning returns. Also, antibiotics can affect absorption of PD meds and sometimes doses need to be increased or decreased. Hope that helps.
  23. Question on Cognitive episodes

    Thank you for the note. One thing I always tell people is to not hang your hat on the DAT as sometimes it is not right or the situation changes. Having said that I would definitely seek a full neuropsychological testing profile looking for other things like seizures or Lewy Body Disease or another illness as the behavioral features sound worrisome. Good luck.
  24. Tremor-dominant subtype

    I am only commenting on Parkinson patients with tremor. Literature suggests that if you have tremor that 20% or more of cases will have an incomplete or no response to dopamine (only the tremor feature as the other features like rigidity usually respond). I am so sorry if I confused you!