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jas1125

Too much or too little Stalevo?

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Mark:

 

My mother, age 85 takes Stalevo 150 five times a day. Starting at 6 AM, ending at 10PM with 4 hours between. Until recently, she also took 1/2 Parcopa 25/100 as a "booster". She had bronchitis and a fever a few week back that landed her in the ER...fever, confusion etc. The infection and fever resolved in a few days on a Z-pack, but about 2 weeks after late she has been having pretty substantial dyskenisias, starting about 1-1/2 hours after taking her dose. She's in an assisted living facility and I've had them change the 1/2 parcopa to a PRN and not include it. Removing that has helped a bit but she's still getting them and it's hard to tell if she's getting too much or not enough, but the normal added Parcopa definitely made it worse. She is due back to her neuro in 2 weeks, but I wanted to get your opinion on modifying her meds. She's also lost some weight, not a great deal but about 5-10 pounds and she's at 135 lbs.

 

She's had a small amount of cognitive decline over the past year....not much, just some short term memory issues and I know that Stalevo might add to that. Overall it's been a good drug for her and with her being in assisted living, it's also easier to monitor with the med techs who dispense her medications. In addition, she takes Lexapro 30mg/day, Nortip10mg/day, Plavix 75mg, Protonix 60mg, Aldactone, Mucinex and a full compliment of vitamins (multi, CoQ10, Cranberry with D-Mannone and NAC)

 

At her age, it is better to try to lower the Stalevo from 150 to 100 and try that, or keep her on the same dosage and add Amandatine for the dyskenisia? She tried amantadine a few years back, but it made her light headed and we stopped (at that time, the dyskenisias weren't that bad). If we try it again, I'll ask to have her start at 100/day and slowly increase. There's a chance she's not back to her baseline after the infection but it's been almost one month now.

 

Any information would be appreciated...thanks and hope you're doing better.

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I am doing better, thank you.

As far as mom is concerned, I was going to warn you that the amantadine : old cause some additive affects like lightheadedness and dizziness.

I would rather see you take to the dr about lowering the dose of stalevo. I believe this may be too long acting for 5 times a day.

Here are some interactions of some of the other meds and interactions with the other meds she is on:

Using entacapone (an ingredient in stalevo) together with escitalopram (lexapro) may increase side effects such as dizziness, drowsiness, and difficulty concentrating.

 

Using escitalopram (lexapro)together with clopidogrel (plavix) may increase the risk of bleeding. The interaction may be more likely if you are elderly or have kidney or liver disease.

Talk to your doctor before using clopidogrel (plavix )together with pantoprazole (proronix). Combining these medications may reduce the effectiveness of clopidogrel in preventing heart attack or stroke.

 

 

 

Treatment with escitalopram (lexapro) may occasionally cause blood sodium levels to get too low, a condition known as hyponatremia, and using it with spironolactone can increase that risk. You should seek medical attention if you experience nausea, vomiting, headache, lethargy, irritability, difficulty concentrating, memory impairment, confusion, muscle spasm, weakness or unsteadiness, as these may be symptoms of hyponatremia

Levodopa (a product in staleco) and spironolactone (aldactone) may have additive effects in lowering your blood pressure. You may experience headache, dizziness, lightheadedness, fainting, and/or changes in pulse or heart rate.

Using nortriptyline (pamalor) together with entacapone (an ingredient in stalevo)may increase side effects such as dizziness, drowsiness, and difficulty concentrating. Some people may also experience some impairment in thinking and judgment.

Talk to your doctor before using escitalopram (lexapro) together with nortriptyline (pamalor) Combining these medications can increase the risk of a rare but serious condition called the serotonin syndrome, which may include symptoms such as confusion, hallucination, seizure, extreme changes in blood pressure, increased heart rate, fever, excessive sweating, shivering or shaking, blurred vision, muscle spasm or stiffness, tremor, incoordination, stomach cramp, nausea, vomiting, and diarrhea.

Now this is not to say that all of these side effects or interactions will happen, but they are possible interactions with the medications may cause. So, I may recommend the dr. May do a complete medication review and look at all her medications to see if any of these medications may be causing some of these issues or other issues she may be having.

Please keep me posted.

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Mark:

Thanks for the reply and glad to hear you're doing better.

 

In the interim, she had her appointment and we landed on changing her overnight dose of Sinemet CR 50/100 to regular Sinemet. In re-reading my post, I negleted to mention that she had a bridge dose at 3AM of the CR. In fact, I read more of your prior posts before the appointment and saw that the CR stays in your system quite a while. Since making that change, her dyskinesia's are much improved, although she's a bit stiffer in the morning at times. We changed the Parcopa to a PRN so she can ask for it when she needs it. We did discuss lowering the Stalevo dose, but her neuro feels that after 14 years with PD, she's doing well overall with the 150. We also discussed amantadine and she does not wish to try it and if needed, will explore a lower Stalevo dose instead. Next follow up in 4 months.

 

Thanks for the info on the other potential interactions. Anytime she gets a new med or adjustment I go to Medscape's Drug Interaction site to reseach them. They listed some of the ones you did also and what I like is that it gives a critical warning message on higher potentials. I was especially concerned with the Nortip and Lexapro, but after discussions and more web searches, the 10mg dose of Nortrip seems to be doing well for her.

 

I want to thank you for the time and detail you and the rest of the staff put in when responding to questions such as these. Doing forum keyword searches gave me more info so that I could ask better formulated questions to her doctors. In fact, when I brought up amantadine, her doctor asked if I was a medical professional. I replied no, but I read a lot and ask questions on the NPF site :)

 

Thanks again Mark and hope things continue to improve for you

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Mark,

My mom is constantly walking with her knees bent.  Is this a sign of too much or too little Stalevo?   I have increased it slightly and it didn't seem to help after 2 weeks.  It's all too confusing to know what the signs are for when you need more or less.  Do we go up or down?   Any clue or personal experience with that?

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Seeker,

By the sounds of what you are describing it sounds like stiffness and reduced dexterity. This is a sign of PD which would coincide with the lack of Dopamine. Without actually seeing her it is hard to be completely correct, it is an educated guess. I say that because when a symptom occurs in a PD patient it usually happens most on the side affected by the PD. Since this is in both legs, unless she has severe PD, it would be odd that it happened in both legs. 

It may also be dystonia (which is basically a severe muscle spasm) which originates from the same part of the brain that PD does, which is the basal ganglia. Dystonia can happen secondary to PD and usually comes about from taking Levodopa, and ingredient in Stalevo. This can happen on both sides of the body and can also include the upper and lower back. The odd thing about dystonia is that it can happen in two different scenarios:

1) On-Period dystonia: This dystonia happens when the medication is working to alleviate all the other symptoms, then dystonia happens.

2) Off-Period Dystonia: This Dystonia happens when the effects of the Levodopa are wearing off and the symptoms of PD are also apparent..

This can somewhat narrow down what type of dystonia it is and therefore can also lead one to determine which track to take, either adding levodopa or decreasing levodopa. This is also the reason I always recommend that you keep a journal of medication, time of dosage,  times of eating, and the time any effects may happen. When you look back over the journal, many times you can see a pattern of some sort. If you look on my main page of this forum you will see a topic entitled, Medication Schedule." You must have Microsoft Excel in  order to use this, but the nice part is that the journal can be kept on line and updated daily or printed out and fill it out. This can then be emailed or faxed to the Dr. a few days prior to the appointment so the majority of the appointment time is not spent on "What has happened since your last appointment?" The PD Dr's, and all Dr's I have encountered, love this idea because it saves them time and also saves you time. During the appointment a plan of action can be made and several other avenues can be made if the first choice does not pan out.

The best way to be 100% sure would be to take her to her Dr. or a Movement Disorder Specialist, but knowing the above information can greatly help the Dr in their decision making.

As always, I hope this helps and please keep me posted.

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